Primary Care Coding Alert

Answer: The answer to your question depends on the strength of the Kenalog mixture used by your provider in the encounter. The descriptor for J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10 mg) cites 10 mg for each unit of service as you say, but until you know the strength of the dose your provider administered, you cannot assign units.

Kenalog comes in two mixtures: 10 mg/mL and 40 mg/mL. If your provider is using the 10 mg/mL dosage, then 4 mL administered would be J3301x4. But if the patient is receiving 4 mL of Kenalog in the 40 mg/mL strength, then you would document J3301x16.

Example: Your provider administers a 1.5 mL dose of Kenalog to a patient using the 40 mg/mL mixture of the drug. You would bill this service with J3301x6, as the patient is receiving 40 mg of the drug for every mL your provider administers (40 mg x 1.5 mL = 60 mg, or 6 units of 10 mg).