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second guessing..

  1. #1
    Stuart, Florida
    Cool second guessing..
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    Ok, sometimes I get to thinking about something and it makes me question whether or not it's getting done correctly. I wanted some input as to how you would all code this situation:

    Patient comes in for a scheduled injection. Patient does not see the doctor during this visit, only comes in and goes straight to lab for injection by MA. There is no doctor's note for this DOS. Injection, with NDC#, is logged in chart on Lab Log. For comparison's sake, how would you code this encounter if, say, patient comes in for Procrit 20,000 units?

    Also, is logging it on Lab Log with the NDC good enough documentation?

    Thanks in advance!
    Last edited by ohn0disaster; 08-20-2010 at 01:13 PM.
    Vanessa Mier, CPC

  2. #2
    Columbia, MO
    The person giving the injection must document in the chart that the injection was given per the physician order, we even made ours put the date of the original order, and the location on the body of the injection site. not documented then it was not given, you only have a case made that the drug was drawn up to be given.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Stuart, Florida
    It's unfortunate because, regardless of the times that I've told the doctors, arnp, MAs, and xray tech that a verbal order is not DOCUMENTATION, it seems that they choose laziness. I don't get the charts, so lots of times I have to trust that they are doing their jobs. HAH! A lot of our patients are humana goldplus, which we're capped with. Fortunately, the billable encounters are put together at the end of the month with everything needed to bill for the billing department of our company. We end up having to go back and do triple the work to make sure everything is in order(because, even though they've been told 2897932879237 times what is needed, they can't seem to keep it consistently together). We copy the note where the original order was given and send that. I know they don't consistently document the location the injection was given though. Sometimes being a coder feels like being a babysitter, constantly cleaning up messes and making sure everyone is keeping up their end. BLAH.

    Thanks for your response, Debra. I appreciate it!
    Vanessa Mier, CPC

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