Procedure notes don't have to be in a completely separate note. They must be separately identifiable though and can't be included within say the physical exam part of a note. When I'm performing both standard E&M office visit for say shoulder pain, and the visit has not been pre-scheduled for a joint injection/procedure, I will bill a 99213, +25 modifier, J3301 #4 and a 20610. The key is the procedure note be at the very end of your typical office visit. You can do that by adding an addendum or by placing your procedure at the very bottom in the plan. I included my template below to show you how I do it and this has been told to be by several physician coders. The Dr. XXXX at the top is separated by the ___________ this indicates the end of the Office Visit note, the procedure note is documented below that including a Dr. XXXX to conclude the procedure. Within the procedure note you have the location, side of body, indication, etc.
I've never failed an audit and don't only perform joint injections but I perform a fair amount of derm and osteopathic manipulative therapy.
Shoulder Injection Template:
Dr. XXXX
_____________________________________________________________________________
Procedure Note: XXXX SHOULDER arthrocentesis
Indication: SHOULDER pain
Injection after verbal consent obtained including a discussion of the risk, benefits and alternatives (including oral agents, physical therapy and doing nothing), the patient wishes to proceed. Complications discussed include but not limited to: pain, infection, steroid flare, fat necrosis, skin discoloration, and injury to blood vessels and/or nerves. The anatomic site was sterilized with chlorprep solution and under sterile conditions the anatomic site was injected with a solution of local anesthetic and 1cc of kenalog. The patient tolerated the procedure without immediate complications. Patient is instructed to call the office if any signs or symptoms of infection occur including significant increase in pain, warmth, redness or drainage at the injection site.
Dr. XXXX
