Forum - Questions & Answers
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?
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.
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.....