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nonadianne

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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.
 
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