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Click here for more sample CPC practice exam questions and answers with full rationale

Where can I find what is required to be in a procedure note?

Does anyone know where I can find out what needs to be in a specific procedure note? i.e: Laceration Repair note, Reduction, etc. We have providers stating the information is in the documentation but it isn’t always complete. I was hoping there was something that spelled out what information needs to be included so we can give them exact feedback on what is missing.

Thank you in advance.

Medical Billing and Coding Forum