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Injection "verbage" on notes/chart

  1. #1
    Cool Injection "verbage" on notes/chart
    Medical Coding Books
    Quick question- in regards to charging out for an injection-say Ortho MD injected Depo Medrol to knee (I would code 20610 and J1030 depending on cc's administered)- BUT in the physicians actually note MUST HE PUT THE VERBAGE "under sterile conditions I injected left knee w/20 cc's of Depo-Medrol and patient tolerated it well" ..???? Noone of the physicians in my new office do this, yet I had physicians in a prior practice whom always did. Is this really a non-issue or something I really need to address with the physicians at my new clinic.

    Thanks to all replies.

  2. Default
    AAOS article from Oct. 2009 addresses this.

    From the article above: "Because injections are considered surgical procedures, they require a procedure note. The procedure note should include a signed consent, documentation of the anatomic location, preparation of the site, local anesthetic administration, name and dosage of drug administered, and patient reaction. Documentation should also include all postoperative instructions related to the minor surgical procedure."

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