Wiki Documenting WWE and E/M same day

[Natalie White]

Help, I'm getting different answers. I've always had my physicians do separate documentation when an E/M code and an in office procedure were performed on the same day. Does this hold true for a WWE and office visit performed on the same day? I know the rules that would allow for these to be billed on the same day, its the documenting that I am questioning. Should a separate office not be done for each or can the physicians include notes/details for both under one clinical documentation?

 

[01077395]

They should each have separate documentation. Also keep in mind any history and exam elements cannot be used twice when determining E&M level for the problem visit. So if you count something in the documentation for the WWE, you cannot count it for the problem E&M.