Primary Care Coding Alert

Question: When a patient comes to one of our providers for an injection, does the coding differ depending on whether we supply the medication injected versus the patient bringing the medication? Is a J code required in one of these situations?

New Jersey Subscriber

Answer: Yes, generally you would adjust your coding to reflect whether your office provided the medication as well as the service. The documentation for the injection should include the relevant diagnosis code, the reason for the injection, the amount of medication injected, the date and time, which provider ordered the medication, and the name of the provider who performed the service — as well as where the medication was injected into the patient.

For example, if the patient brings in B-12 or testosterone or something else provided by a pharmacy, it may be appropriate to use CPT^® code 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular). If the patient arrives for an injection of an antiemetic provided by the practice, then you might code 96372 and a J code, which shows that the medication provided was designed to be taken non-orally.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC