Utilize Separate Notes
Question: We sometimes see patients who come in for services relating to incidents involving workers’ compensation (WC). When we make an appointment for WC cases, we’re supposed to add a reminder for the provider saying “Separate notes.” What does this mean? Maine Subscriber Answer: In the context of WC, “separate notes” is a policy or process of keeping the records relating to the WC services separate from the rest of the patient’s medical record. For example, if the patient has a heart arrhythmia and takes medication to manage it, but smashes their thumb while at work, then the heart arrhythmia diagnosis and management is probably unrelated and documentation concerning the injury (including treatment) should be made and kept separately. Depending on your state, this may or may not be a compliance requirement. Keeping separate records for WC protects the patient’s privacy and allows a provider and practice to stay organized — particularly because documentation and records for WC cases often need to be submitted to entities other than the patient’s regular payer. Failing to keep separate notes for WC cases can lead to confusion or even misinterpretation, so a comprehensive policy can help prevent a lot of headaches. Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC
