# Does each procedure note need to stand alone???



## maryir (Aug 23, 2017)

I posted this question under Anesthesia and Compliance but only received one response. I could use some help here if anyone has an opnion, I'm open to hearing what you have to say.

I have a GI physician who is charging for Moderate Sedation while performing two separate procedures, an EGD and a Colonoscopy. The Moderate Sedation is noted in one note (the Colonoscopy) describing the Moderate Sedation, which includes the time recorded for both the Colonoscopy and EGD.
The Dr is stating that he performed one procedure immediately after the other and that the documentation of the Moderate Sedation within the one note is sufficient.
I’m stating each note must be independent. That the Moderate Sedation should be noted in both notes.
Am I looking at this wrong?


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## thomas7331 (Aug 24, 2017)

Although this could create some confusion if reviewed, it should not be necessary to duplicate information in the patient's medical record as long as the codes that you've submitted are supported in the documentation and the record is complete and has the provider's attestation.  If audited, you are not limited to submitting just one note from the patient's chart to demonstrate that your coding is correct.


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## jfolz (Aug 24, 2017)

thomas7331 said:


> Although this could create some confusion if reviewed, it should not be necessary to duplicate information in the patient's medical record as long as the codes that you've submitted are supported in the documentation and the record is complete and has the provider's attestation.  If audited, you are not limited to submitting just one note from the patient's chart to demonstrate that your coding is correct.



I agree completely as long as there was no interruption of sedation between those procedures.


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## trish4560@snet.net (Sep 20, 2017)

I agree, too. As long as there is no interruption of sedation between procedures no additional note is needed.


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