Your written documentation is in CPT Nomenclature under the introduction to the surgery guidelines:
CPT Surgical Package Definition
The services provided by the physician to any patient by their very nature are variable. The CPT codes that represent a readily identifiable surgical procedure thereby include, on a procedure-by-procedure basis, a variety of services. In defining the specific services "included" in a given CPT surgical code, the following services are always included in addition to the operation per se:
Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
Subsequent to the decision for surgery, one related Evaluation and Management (E/M) encounter on the date immediately prior to or on the date of procedure (including history and physical)
Immediate postoperative care, including dictating operative notes, talking with the family and other physicians
Writing orders
Evaluating the patient in the postanesthesia recovery area
Typical postoperative follow-up care
Keep in mind that if a medical condition outside of the reason for surgery comes up within the global an e&m or another service, these may be reported separately with the appropriate modifier. Also, the H&P is subjective depending on your specific factors for a patient, in other words; this may be separately reportable as well.
