Injection coding

jgossett

Networker
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Franklin, KY
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I realize this is probably a coding 101 question, but what needs to be documented in the medical record to code for an injection?
 

aaron.lucas

Expert
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Cherry Hill, NJ
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I do code review for a PIP vendor in NJ, and for us it depends on the type of injection. For surgery codes (sacroiliac, epidural, joint/bursa) we require an operative report, but for something like a
sub-q/IM or IV (96372/96374) we just look for something noting the injection and what was injected. usually the 96372 is along with an OV so we look for it in the plan section and it might say "injected XXmg Toradol into left buttock". does that make sense?
 
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