April 16, 2008
Therapeutic Injections
During the course of each day, providers often administer medications as part of a course of therapy. These agents include but are not limited to antibiotics, steroids and similar agents.
CIGNA Government Services has noted that the documentation regarding injections is sporadic at best. Expected documentation is noted below.
Documentation Expectations for Injections:
- Physician order noting drug, amount and route (IV, IM, subcutaneous)
- Nurse should document:
- Drug, lot number and expiration date
- Dosage given and any wastage if billing for same
- Site and route of injection
- Date and time of injection
- Signature of person giving the injection
- Presence or absence of any adverse reactions.
- Prudence would also recommend that the person giving the injection double check for allergies and note same before giving an injection.
While not all of these bullet points are required by Medicare, having them in place allows your billing staff ready access to the information necessary to properly bill for the drug(s). Medical review systems (for example, CERT) can determine that the injection was given and correctly billed. Billing staff should pay close attention to proper units when billing for drugs.
The documentation should be maintained in the medical records and available for review by Medicare upon request.
