Auditor's

[daniel]

In regards to CPT 90772- injection.

if the M/A or nurse provideds this service. Let's say they inject a vitamin B12 shot.

What do you look for in the documentation? Can you provide me with a brief example in your reply.

Respectfully
Daniel, CPC

[apeck]

A vitamin b12 injection is usually for pernicious anemia which is a form of anemia which is caused by a type of gastroectomy (spelling is probably wrong), but look for some type of gastro surgery because is causes a vitamin b12 deficiency. In simpler terms they had part of their stomach removed. I only know this because I have a patient that comes in every month for an injection. If it is only documented as anemia it will be rejected, so make sure you look for this particular type of surgery. You might have to go back at look at past surgery's to see if this is true or documented anywhere in the chart. I hope this is helpful.

[daniel]

your reply is very helpful. But I'm looking for direction in how to teach M.A's and the nurses how to document the injections they provide. I have an idea how I would direct them. But seeking other input from auditor's on what they look for when they audit chart's for injections.

respectfully
daniel,cpc

[apeck]

What we look for is the dr. orders it and the nurse puts given next tothe order or in her notes at the bottom of the visit, in the progress note, or the immunization record including the im injection and the site of the injection. Alot of times if they write given and initial it this passes as sufficient documentation.

[daniel]

makes perfect sense. Thank You

[apeck]

Your welcome, but I have an added note that I came across today and reminded me to add to this. If the immunization is ordered but not carried out it also needs to be documented and the reason why it wasn't given. There are a variety of codes we use for the reason the vaccination wasn't given.

[cheermom68]

As an RN, I was taught all of the following would need to be documented.
Date,time,type of injection and medicine given, site given, patient response and education given and signature. Of course you would also want to make sure there is an order. An entry might read
1/8/09 1400 25mg toradol IM LLQ lt hip, tolerated well, instructed to stay 15 minutes with no driving, may cause drowsiness, dizziness. MSMITH RN
This would cover both the billing of the injection and what is required for the safety of the patient and your practices liability.
We have noticed alot of offices that we audit are not documented lab draws or injections appropriately.
Hope this helps.