Home Forums Discussions Problems Documenting procedure notes

I'm new to the boards and used AC for a couple of years before joining a group in 2005 that used a different EMR. I may be coming back to AC, but need a way to document a procedure note in a pain practive (epidurals, joint injections, nerve blocks, etc) without making a full progress note. Has anyone found a way to document a procedure this way? I have found a few suggestions, but I was wondering if their are any other pain docs or procedure oriented practices using the system. Thanks.

I just have templates for each of my injections (facet joint, knee, epidural, etc) and I just put them in the plan section and sign off. You could just have your nurse put "patient is here for x procedure in the HPI section and then you do the a/p section

You can also put it in the addendum section, which has the ability to bill from these notes.

One would think that a progress note entry would be best, labeled as a procedre note. The problem is that if done this way, you are penalized in this program an insufficient meaningful use docomentation and it counts against you.

It would certainly be nice if you could make such an entry and activate a button or icon on the program which would exclude the entry from either the numerator or denominator of the meaningful use tracker

Bruce Morgenstern
Denver CO

Yeah, I don't take gov insurance so I just have MU turned off so I couldn't speak to that.

If I am not going to do a separate office note so I only have a procedure to document I use addendum - have templates and I just choose - Addendum - changed to procedure in box on top - label the subject with for instance - corticosteroid injection of left knee and then use that template. When I bring up the pt. chart and look I can scan through and quickly see when it was last done (great for things you tell a patient they cannot do more than 2 times per year, etc).

This is great and you can make a superbill for the addendum at the end.

As someone who performs procedures daily and who types some of the notes himself, I was hopeful that AC would make it easy to do so within the patient's chart. My conclusion is that the program can't do this well enough (especially with its limited formatting ability). The solution I use is simply to create reports in Word and import them.
If I did create the reports in AC, I would likely use Steven's method.

I agree with Bruce that the program's counting for MU has created an additional reason NOT to create a progress note to document a procedure. One approach would be his idea: a button which would keep the note out of the MU counts. Another would be to automate the process: only visits coded for visit E and M codes (those which are included in MU) should count towards the totals. Any other note (including procedure notes and those created for other purposes; e.g. to enter information at times other than a visit) should not be counted.

This is a potentially important issue; I think AC needs to fix this automatic counting. The program should be sophisticated enough to know if a note should be counted towards MU.

Has anyone checked to see if the procedure notes are being counted in MU?
I agree that since you have to put in the CPT codes they should be checking and only using the visits with E&M codes for the MU counts. But has anyone looked to see if they are counted?

Greg

All:

I do injections (knee,shoulder,hip,back,SI joint, etc) daily in my office. In order to bill for a procedure you need to have a SEPERATE note and it can't just be in the plan. Here is what I do. I have templates for all my procedures and work with those each time in the plan of the note. This way i have access to the procedure note reviewing my notes...but then i copy the text of that procedure note and then when i close out the note i add an addendum and paste the note. i don't ever bill from the addendum just as part of the superbill for the day's note.

It is a bit annoying and i wish AC would allow you a tab for procedure note and then automatically make a procedure note out of it but it doesn't yet.

Btw , those of you doing xray in your office, you need to have a seperate note for the documentation of the xray and the read in order to bill for that!

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

Slater,
I've done that as well in my current ehr. For something like Orthovisc/Synvisc the next two visits I do only the injection. After playing with AC, I think I would do a separate note with a -25 modifier and the injection as an addendum just to keep everything clean and easy. It would be nice to be able to do a procedure and have it placed with the notes but be labeled as what procedure was performed. I'm working on templates for every procedure and will probably be up and running by the new year. I'm still playing around with sending notes to the referring docs and would like to send the hpi and plan only with the letters I send.

Some procedures, like GI procedures, may be documented with the software associated with that equipment. For GI endoscopy, for example, our hospital uses Provation. I then print a copy of the report to a thumb drive using CutePDF ad import it to Imported items. This does not speak to MU, of course, and as an imported item is not exactly part of AC in that it does not flow seamlessly into the record in the proper chronological sequence. Documenting as an addendum is a good idea, but I'd lose the pictures. But, I see that as just another example of my main rant about the state of the electronic record in general; it is one giant tower of Babel.