Forum - Questions & Answers

Mar 11th, 2010 - akajbart

E/M visit and office procedure - same day

1) What documentation is required for an office procedure note (bone marrow biopsy, colposcopy, endometrial biopsy)?

2) Can the documentation be listed on the same page as the E/M dictation, or should it be listed separately to justify that it is separately identifiable, since we are appending the 25 modifier?

Mar 11th, 2010 -

Two answers

1- document to prove you did it for auditing and document to prove to a lawyer you explained risks and benefits and did it right.
2-The same page is fine as long as there is a clear separation of the E&M and procedure. I have done ear washes and in the Exam I write "wax occluding canal. Ear lavage with warm water performed with syringe and great difficulty and large amount cerumen removed. TM now visible and normal" and I bill for E&M and lavage.

Mar 17th, 2010 - Codapedia Editor 1,399 

E/M and procedure

There are articles about modifier 25, so you can review those.

If you are using a form, say for a colposcopy, then you need another note for the E/M, assuming it meets the criteria for a separate, E/M service.

If your doctor is dictating, then you can ask him/her to dictate a section in the objective portion:

Procedure: Using sterile.... I..... The patient.....



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