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Our attending Phsysican at a SNF was doing a progress note on a resident who was complaining of shoulder pain and requested a cortisone shot. The physician noted that he injected Decadron into her left shoulder. He did not put how much just that he did the shot. Can I bill for the injection along with the E/M or do I not code the injection, due to lack of information. The resident has osteoarthritis in the shoulder. Please advise.
Thank you in advance for your assistance.
If it was not documented it was not done. therefore if he does not give you information on the injection you can not code it. if possible qury the physician to see if he can amend the documention to include the amount and strength of the Decadron he gave to the patient.