procedure documentation

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    Wiki Can you bill an E/M (LOS) instead of a minor procedure?

    Hello, I am doing research on what types of procedures are NOT significantly separate and are typically performed as part of an exam. So far my research has led me to the following types of services that a LOS is billed instead of the procedure: 1. Pap smears when a patient presents with...
    • arbucklej
    • Thread
    • bundled or billable evaluation & management evaluation and management level of service minor procedure minor surgery procedure code procedure documentation
    • Replies: 0
    • Forum: E/M
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    Wiki Joint Injections

    I have an ortho provider who is refusing to document his procedure further than "today we injected the knee with 40mg kenalog" I am trying to explain to him that any and all procedures should include at minimum: 1) Indications for procedure (medical necessity) 2) Anesthesia/Medication given...
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    Wiki Can an Injection note be put in the middle of the E/M notes.

    Hi, I have a provider that is putting his procedure notes in the middle of his E/M notes. Does he have to Put his procedures on a separate page? Does anyone have a resource/guideline stating how a procedure has to be documented? I could only find one thing on this and it was from 2014 and...
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