What is "inherent" to injection 96372?

ollielooya

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When an patient presents themselves for acute care treatment of a explosive headache (patient has presented themselves before to the practice for the same issue), injections are sometimes the course of treatment. Basically what is the minimal patient examination process that is inclusive of this code? I have not worked the clinical side and would like to know what is involved. Minimal documentation does not always support the use of an EM visit with modifier 25.

---Suzanne E. Byrum CPC
 

Mojo

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Hi Suzanne:

96372 would include injection preparation and disposal, patient assessment, provision of consent, safety oversight, supervision of staff. Documentation should include VS, allergies, explanation of the procedure, observing the patient post injection and discharge instructions related to the injection.

For the presenting problem of an explosive headache, best practice would dictate a neurological exam to rule out a SAH, mass, thrombosis, stroke... or to determine if imaging is needed. With supporting documentation, an E/M would be reported.
 
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