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Procedure separately documented

  1. #1
    Default Procedure separately documented
    Medical Coding Books
    If a physician documents an evaluation and management encounter, and also does a procedure on that same day in the office, does the procedure have to be separately documented? I have a physician that always documents the procedure within the E/M documentation.

    Palmetto says, "If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the specific procedure should be documented."

    Palmetto doesn't specifically say that the procedure has to be separately documented. It only says documented.

    Can I get any one elses thoughts on this?

    Tiffany Fischer, CPC, CEMC

  2. #2
    I don't believe its mandatory it be a separate note but there must be significant info in the e/m note to substantiate the procedure.

  3. #3
    Milwaukee WI
    Default Separate paragraph
    It does not have to be a completely separate note, but I do ask the doctors to at least start a new paragraph and title it "Procedure:" This makes it crystal clear to the coder (not to mention an auditor) that a distinct procedure was performed.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #4
    I think if the procedure is documented then you should not have problem, unless specific payer requires separate notes. We document all procedures in one note.

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