How Many Notes

February 1, 2004

If a patient schedules an appointment for a work-related injury, then presents another acute problem to the physician, how must the visit be documented to justify billing both workers' comp and the patient's private insurance? Are two separate notes necessary?

Question: If a patient schedules an appointment for a work-related injury, then presents another acute problem to the physician, how must the visit be documented to justify billing both workers' comp and the patient's private insurance? Are two separate notes necessary?

Answer: A single note to document two services is fine. Of course, both services need to be supported. That is, if an auditor from either carrier were to review the record, each should be able to pull out her company's documentation requirements.