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injection documentation

  1. #1
    White Plains, NY
    Default injection documentation
    Medical Coding Books
    I have a dermatologist that bills for injections for alopecia and acne, but never bills for the medication. The name of the medication is mentioned in the record, but not amounts, or lot numbers or anything - just its name. I seen to recal a Medicare regulation that says that you need to couple billing the medication used with the injection - but perhaps that is just for innoculations.

    Anybody have an idea here?


  2. Default
    Anytime your office provides the drug for a service or procedure, the J code for the drug is coded. One exception is if the drug was at no cost to the practice (ie drug rep sample or pt brings in the drug).

    The physician must document the drug and dose in his order. The dose administered must be documented as each J code is based on a specified dose. The # of units billed are based on this defined dose. The nurse can include the lot # in her documentation

  3. #3
    White Plains, NY
    Let me see if I have this straight:

    So injections for acne and alopecia are not based on the number of lesions treated but the amount of the medication injected? Therefore, if the detail on the medication is neither documented in the record, nor billed with a J code, could the injection get denied?

  4. Default
    You code for the CPT for the injection procedure itself. You also code the J code for the drug injected. For example

    11900: Injection, intralesional; up to and including 7 lesion
    J3301 10 mg Kenalog (1 unit given/coded/billed)

    The 11900 won't get denied when coded/billed alone, the practice will just not recover the cost of the drugs they bought/paid for

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