I’m holding these services until I can get a definitive answer –
I have a GI physician who is charging for Moderate Sedation while performing two separate procedures, an EGD and a Colonoscopy. The Moderate Sedation is noted in one note (the Colonoscopy) describing the Moderate Sedation, which includes the time recorded for both the Colonoscopy and EGD.
The Dr is stating that he performed one procedure immediately after the other and that the documentation of the Moderate Sedation within the one note is sufficient.
I’m stating each note must be independent. That the Moderate Sedation should be noted in both notes.
Am I looking at this wrong?