Question

Which statement is TRUE regarding documenting a minor surgery during an E/M service?

a. There is no documentation required for a minor surgery if it is performed during an E/M service.
b. A separate operative report is required for the minor surgery.
c. The documentation for the E/M service and the minor surgery can be on the same page, but are required to be separate paragraphs.
d. The operative report can be included in the documentation for the E/M visit and is not required to be separate.

Answer 1

The correct statement is that documentation for an E/M service and a minor surgery must be on the same page but in separate paragraphs to ensure proper coding and billing.

Step-by-step explanation:

The statement that is TRUE regarding documenting a minor surgery during an E/M service is that the documentation for the E/M service and the minor surgery can be on the same page, but are required to be separate paragraphs. When a minor surgery is performed in conjunction with an Evaluation and Management (E/M) service, it is necessary for the health care provider to document each service distinctly to ensure proper coding and billing. The E/M service should have its own documentation reflecting the complexity of decision making and any evaluation of the patient before the procedure, while the minor surgery needs a concise operative note documented in a separate paragraph detailing the procedure itself.