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Injection documentation

  1. #1
    Location
    North Florida Jacksonville
    Posts
    7
    Question Injection documentation
    Medical Coding Books
    I code for the Professional componet and have a question about injections for Antibiotics....Steriods.......Analgesic......Antie metic or any injections given by a nurse.

    I code from EMR's and if the injections are not documented as being given can you charge for them........even if the order was written by the Dr.

    I say NO....but, my superior says YES......

  2. Default
    Quote Originally Posted by vickibrowning View Post
    I code for the Professional componet and have a question about injections for Antibiotics....Steriods.......Analgesic......Antie metic or any injections given by a nurse.

    I code from EMR's and if the injections are not documented as being given can you charge for them........even if the order was written by the Dr.

    I say NO....but, my superior says YES......
    Okay, why are you coding the injections if you are coding Pro side and not facility? Facility side picks up the injections, not the pro side. Am I just confused? Now, if you are coding for the facility side, you still have to have documentation that the drug was actually given. If it is NOT documented it is NOT done.

  3. #3
    Location
    Columbia, MO
    Posts
    12,531
    Default
    I too have the same question. If you are in the facility setting coding for the physician, then you can code for only what the physician performs. Anything performed by nursing staff is coded by the facility only. But to go further then and answer the question about can you code it. If you were the facility coder and you saw an injection had been ordered but never documented as performed you would never code it as per the documentation it was never administered.

    Debra A. Mitchell, MSPH, CPC-H

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