Wiki Need a reminder on this..

[Love Coding!]

Ok, my physician did an injection of epoetin alfa J0885 w/ 96372 intramuscular injections.. this is a very simple question...

On the physicians documentation for the visit, is he required to document that this injection was given during the visit? Or is it sufficient that he has documentation of ordering it? Orders and dictation are two seperate records...

Thank you

 

[ajs]

Ok, my physician did an injection of epoetin alfa J0885 w/ 96372 intramuscular injections.. this is a very simple question...

On the physicians documentation for the visit, is he required to document that this injection was given during the visit? Or is it sufficient that he has documentation of ordering it? Orders and dictation are two seperate records...

Thank you

There needs to be documentation of the injection itself. The ordering of an injection does not give the same info as the actual injection...site, reactions, etc.

 

[Love Coding!]

There needs to be documentation of the injection itself. The ordering of an injection does not give the same info as the actual injection...site, reactions, etc.

Good morning Arlene,

Thank you, I just want to make sure that I am instructing the physicians correctly..it was told to me that if there is proof of them ordering it, that it was sufficient enough to bill.

Have a great day!