Wiki Office Procedure note

[KoBee]

I am getting mixed information as to what is considered compliance or not in a patients chart note to support an in office procedure, can any one help or take a look at the following example if this is acceptable.

CPT 20610 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance

Provider chart note:
Hip pain = Toradol injection 30mg
Acute pain of left knee = Toradol injection 30mg

Instructions and warnings given

Is this sufficient?

 

[amyjph]

In my opinion that is not enough. The procedure note can live inside the chart note for the day but that documentation is very lacking to report 20610.

Here is another place we discussed: https://www.aapc.com/discuss/threads/procedure-note-documentation.192019/

 

[TTcpc]

In my opinion that is not enough. The procedure note can live inside the chart note for the day but that documentation is very lacking to report 20610.

Here is another place we discussed: https://www.aapc.com/discuss/threads/procedure-note-documentation.192019/

I agree with Amy's response and the earlier thread that she refers back to has very useful information that you can utilize to educate your provider. I personally would feel it would not support and would query/educate the provider in the requirements.