Wiki IM Injection in the ED

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Coder Bradley

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Patient came in and recieved Norflex, Toradol and Dilaudid.
The provider gave a second Dilaudid IM (96372) 1.5 hours after the first, can this be counted seperately?
 
If it is documented that the meds were given together in one syringe, then you would need to code accordingly. Commonly Toradol and Dilaudid are given together in one injection. You can still bill separately for the additional Dilaudid. I would make sure of the documentation before assuming that 4 separate injections were given.

Heather MacPherson, LPN, CPC, CPC-H
 
Heather,

In all of my years coding ED, I have never come across those two drugs being done in the same syringe. However, I am not saying that they can't either.. I just have never seen it. I guess I automatically assume when responding that they know of this and are looking for it. I took it as it being 4different injections. I guess there could have been some in the same syringe but did not look at it that way. I am sorry if I confused anybody. Like I said, I assumed these are all different meds given at different times in different syringes.
 
erthsvr said:
If it is documented that the meds were given together in one syringe, then you would need to code accordingly. Commonly Toradol and Dilaudid are given together in one injection. You can still bill separately for the additional Dilaudid. I would make sure of the documentation before assuming that 4 separate injections were given.

Heather MacPherson, LPN, CPC, CPC-H
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Best practice is to never give multiple medications in a single syringe when avoidable due to time associated with specific drug administration, interactions, dilution requirements, etc. Unless documented otherwise, each syringe injection would be coded and billed separately.
 
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