Primary Care Coding Alert

Question: Does our provider need to document vital signs before we can charge an [injection] administration fee?

Illinois Subscriber

Answer: Payers don't usually require documentation of vital signs for billing purposes related to administering injections, but most providers check the patient's blood pressure and temperature before administering injections for other reasons (e.g., quality care, compliance with clinical guidelines, etc.). If you report a significant and separately identifiable E/M service in addition to the injection service, include vital signs with whatever E/M code you report: 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...). Likewise, if you consider chronic conditions such as hypertension, diabetes, heart disease, etc., documentation of that should be considered part of the E/M service, since it is not a requirement for reporting the injection administration.