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Wiki Required documentation for billable services - Nurse Visits

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tmelo@ebcap.org

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Hello,
I am looking for guidance on required documentation.
Are SOAP notes and/or EHR master notes required for lab only or vaccine only visits (not with a provider)?
Examples: Nurses Visit: Vaccine only, Nurses Visit: Covid vaccine only, Nurses Visit: Lab work (G0328, 82962, etc.)
I appreciate any feedback!!

Thanks,
Tracey
 
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tmelo@ebcap.org said:
Hello,
I am looking for guidance on required documentation.
Are SOAP notes and/or EHR master notes required for lab only or vaccine only visits (not with a provider)?
Examples: Nurses Visit: Vaccine only, Nurses Visit: Covid vaccine only, Nurses Visit: Lab work (G0328, 82962, etc.)
I appreciate any feedback!!

Thanks,
Tracey
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I would suggest making sure that the patient's MAR is updated. From my experience, a note is not needed for this for vaccinations. However, for labs, if there is blood being drawn, you'll want some way to confirm that the way they took the blood is reported. Also, you won't bill a professional 99211 if there are only vaccinations being done. I have always been told by superiors that you won't bill the level 1 with only vaccines.
 
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