Otolaryngology Coding Alert

Question: In our office, we usually use one note to describe a procedure and an E/M. Why do experts recommend that we write separate notes?


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Answer: The reason for a separate note is that physicians sometimes blend the E/M documentation with the procedure notes, leaving the coder unable to distinguish between the two. The surefire way to show that you performed separately identifiable services is to maintain separate notes -- one for the E/M and another for the procedure.

Many ENT procedures are diagnostic, so physicians sometimes put their findings in the same note with the exam documentation, making it difficult to prove the separately identifiable nature of the E/M service that he performed.

Paper-saver: Separate notes do not require separate sheets of paper. You just need to write separate para-graphs (preferably with clear and distinct headings) -- one for the procedure and one describing the physician's E/M service.