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office visit & minor surgery

Aida Posted Thu 03rd of April, 2014 12:42:31 PM

When billing an office visit because the patient is sick with a URI, sees the doctor. While seeing the doctor, patient states she has several skin tags that she would like removal that same day.

Does the doctor have to do two different notes for each procedure or can he document in the same note for the office visit and removal of skin tags.

SuperCoder Answered Mon 07th of April, 2014 12:43:06 PM

Well, you must be ready to prove that the documentation in the chart supports the submitted codes. One way many offices report successful documentation is with the establishment of two separate chart notes, one for the E/M exam and a separate sheet for the evaluation of the additional problem. In this way, the additional work is clearly documented. It can be difficult to prove additional work/minor surgery was performed when all the information for the exam is contained within the office visit note.

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