Wiki 90471/90472 Is administration SITE documentation required??

[MrsGJones]

Is the administration site (i.e. Left deltoid, etc.) documentation required in order to bill the administration of a vaccine? Please let me know where I can find the guidelines for this.

 

[csperoni]

I do not have a reference for this, as I could not locate one. Here is my opinion on the matter.
For BILLING requirements, as long as the type of administration is documented (IM, SUBQ, etc) is documented, I do not believe the location is required.
For overall COMPLIANCE, I would 100% recommend the practice to document the location. Compliance incorporates more than billing. What if the patient were to develop an infection or complication afterwards at the site? Certain vaccines are to be administered at specific sites. Your documentation wouldn't even state where that was.
If it was inadvertently left out of the records, I would bill the charge and advise the clinician to be more complete in documentation moving forward.
It seems there are specific federal requirements about what must be documented, but site is not one of those requirements. State requirements could differ.
I found this a good common sense reference: https://www.chop.edu/news/technically-speaking-recording-vaccinations-what-required-federal-law

 

[BKzon]

We try to encourage nurses to complete a note that must include the Drug name, dose, and route of administration. It helps to catch when they create erroneous claims in patients' accounts. The note also includes how long the patient waited after the vaccine and if there was any reaction or not. I hope it helps.

PS: I also review the immunization record as a backup. It could be billed with that information, but I prefer the note for compliance.