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Vaccination Documentation

  1. #1
    Location
    Greenville, SC
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    51
    Default Vaccination Documentation
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    Does anyone know if there is a CMS/CPT specific reference that states what must be documented to bill for a vaccine? I have always been taught that the provider (RN, MA, etc), must document the lot #, expiration date, site of injection, date, and their own initals. (Of course some of this can be truncated due to the sticker from the vial that can be put in the chart.) But I cannot find this in writing!!!!

    Can someone help?

  2. #2
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    Quote Originally Posted by kte01a View Post
    Does anyone know if there is a CMS/CPT specific reference that states what must be documented to bill for a vaccine? I have always been taught that the provider (RN, MA, etc), must document the lot #, expiration date, site of injection, date, and their own initals. (Of course some of this can be truncated due to the sticker from the vial that can be put in the chart.) But I cannot find this in writing!!!!

    Can someone help?
    Don't confuse documentation for Billing and Legalaties. The documentation required for billing is an order from the physician and where, what method of administration, and how much was given. For legal or "Policies" within the company, the reason that you put all of the information about the vaccine is because if there is a recall or an adverse affect, you have all of the information about the vaccine to help keep track of what was given. Which helps in numerous possiblities....to many to list. It is just good practice. Most places have compliance policies that are accredited with DHH that they have to go by and this is usually on of the rules.
    Chastity Nault, CPC
    HIM Professional Services Coder - Remote

  3. #3
    Location
    Greenville, SC
    Posts
    51
    Default
    Ok. But is there a specific reference that states "where, what method of administration, and how much was given"? I am auditing a record in which all I have is the order. I do not have any indication where, IM/SQ/OR, etc, or even a dosage. All I have is the MD ordering the vaccine. I just need a reference to back this up and I am having difficulty finding it.

    I truly appreciate your help!

  4. #4
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    Quote Originally Posted by kte01a View Post
    Ok. But is there a specific reference that states "where, what method of administration, and how much was given"? I am auditing a record in which all I have is the order. I do not have any indication where, IM/SQ/OR, etc, or even a dosage. All I have is the MD ordering the vaccine. I just need a reference to back this up and I am having difficulty finding it.

    I truly appreciate your help!
    If you are looking for an Authorative Documentation, you may want to either look on the CMS website, or ask the Physician or Staff if they have a policy that they can show you.
    Chastity Nault, CPC
    HIM Professional Services Coder - Remote

  5. #5
    Location
    Greenville, SC
    Posts
    51
    Default
    Thanks!

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