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Teresa, this has been a bit of a grey area in our office also. It is said that unless you have a separate Dx than the reason for the E/M visit, you cannot bill the admin, however I have seen a directive that states you do not need two Dx codes. If the shot (steroid/antibiotic) is for the chief complaint, and there is only one Dx, does the admin of the shot still get paid?
 
I agree with Teresa. We bill E/M with -25 along with injections, as long as the documentation supports the physician services. If the patient came in just for the injection, such as allergy shots, and did not see the physician, then we do not bill the E/M.
 
sryen1959 said:
Teresa, this has been a bit of a grey area in our office also. It is said that unless you have a separate Dx than the reason for the E/M visit, you cannot bill the admin, however I have seen a directive that states you do not need two Dx codes. If the shot (steroid/antibiotic) is for the chief complaint, and there is only one Dx, does the admin of the shot still get paid?
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Yes, it does as long as the documentation supports the E/M and admin. It does not require separate ICD-9 codes. You should still append modifier 25 because the work is being done for the E/M service. As Emmy1260 stated, if the patient comes in for injections alone and no E/M visit, then just bill the admin and appropriate injection codes.

I hope this helps.
 
emERGENCY ROOM

a 2 YEAR OLD PATIENT WAS BROUGHT TO THE er AFTER SWALLOWING A PENNY. aN EMERGENCY egd WAS PERFORMAED TO REMOVE THE PENNY FROM THE STOMACH WITH SUCESS. wHAT IS THE DIAGNOSIS, HCPCS AND CPT CODE?
 
kemi said:
a 2 YEAR OLD PATIENT WAS BROUGHT TO THE er AFTER SWALLOWING A PENNY. aN EMERGENCY egd WAS PERFORMAED TO REMOVE THE PENNY FROM THE STOMACH WITH SUCESS. wHAT IS THE DIAGNOSIS, HCPCS AND CPT CODE?
Click to expand...
a 2 YEAR OLD PATIENT WAS BROUGHT TO THE er AFTER SWALLOWING A PENNY. aN EMERGENCY egd WAS PERFORMAED TO REMOVE THE PENNY FROM THE STOMACH WITH SUCESS. wHAT IS THE DIAGNOSIS, HCPCS AND CPT CODE?
 
What documentation is needed to bill an admin? I was under the impression that we needed the site, side, and type (IM). I am being told at work that all we need is the type of injection. Which is true in this case?
 
bforr said:
What documentation is needed to bill an admin? I was under the impression that we needed the site, side, and type (IM). I am being told at work that all we need is the type of injection. Which is true in this case?
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This is what I've given my docs for all injection documentation, based on several articles I've read regarding injection documentation requirements:

"Because injections are considered surgical procedures, they require a procedure note. The procedure note should include a signed or verbal 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. Documentation of lot # is not required, but recommended for liability purposes."
 
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