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I have an office where a patient came in and received her flu vaccine. It is only documented in the MAR Summary. Is that enough documentation to justify billing out the flu vaccine?
Does the document state who gave the injection, what exactly the injection was, where/how administered, and signed/dated by the provider of service? If so, then it's likely enough. If not, then I would not bill it.
If you have a compliance department, this would be a good question for them to answer.
This is where it gets tricky. Recently I've had one office, the doctor documented and ordered the patient to get a flu vaccine, but when I checked the NDC number they wrote for it it ended up being a pneumonia vaccine. So when I questioned the office on what was actually given it turned out the patient was given the wrong vaccination. So I'm hesitant on just billing from the MAR Summary because no one knew about the mistake until I brought it up. And it happened a second time the patient was supposed to be given and the Dr. ordered her Hep B vaccination, but somehow the MA gave her a Tdap. So now I have trust issues with vaccinations