Wiki Can an Injection note be put in the middle of the E/M notes.

[adorsey5837@gmail.com]

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 did not really answer my question.
This is what I have https://www.aapc.com/blog/27690-know-when-to-bill-em-with-a-minor-procedure/

It states "Documentation must support both the minor procedure and a separate, independent E/M service (e.g., the E/M documentation must “stand alone”). Although it’s not required, best practice is to separate the E/M note from the procedure note."

But, I need to know if the procedure has to "Stand Alone" from the office visit even if you are not going to bill for the office visit, as it is included in the charge for the procedure. Since the only information I could find on this was from 2014. I would like to have a def-anent answer to take to my provider education people.

 

[thomas7331]

As per the article you cite, it may be a good practice, but it is not required. Many physicians I've worked with over the years have documented minor procedures within the body of their office visit notes, either by their own preference or because their EHR systems were set up that way, and I never once had a problem issue with this any time the notes were audited or reviewed by payers. The one thing perhaps to be aware of is that if the information is not easy to find within the note, a payer auditor may not take the time to look for it, so in cases where you're submitting an appeal, it can be helpful to circle or highlight the information so that the reviewers are sure not to miss it. But as long as the documentation supports what is billed, the format is not an issue.