Wiki Joint Injection Documentation

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KoBee

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Hello -

Sometimes I get confused on what is proper documentation for a minor office procedure (joint injections). I have some providers who don't really enter a proper step by step procedure note, they just put what was done.

Is this okay to still code the joint injection?

Example:
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KoBee said:
Would you agree they are missing detail elements of a procedure, not really describing the procedure.
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I would have to see the whole note, but if that's all it says it doesn't meet requirements for minor procedure documentation. It seems crazy and like extra work but these procedures live in the surgery section of the CPT book. They require proper documentation. And, especially if trying to report an EM with a 25 at the same time. Some practices choose to make a totally separate procedure note which is not a bad idea instead of embedding it in the office note.
The 206__ codes have pre, intra, and post service work associated with the RVUs (10 day global). You would expect to see a discussion of the risks, complications, etc. and consent from the patient. Positioning, prep, performance of the injection, and post work such as bandage/band-aid, patient response, etc. and instructions.


This was talking about eye procedures but it's good info and applies. The basic info is the same.

Another place we talked about it. Searching the forums here can be helpful.

Example of a note (not mine, I googled them): https://www.venturafamilymed.org/cerner-ehr-tips/autotexts/joint-injection-procedure-note

*edited to fix error links
 
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