tci Part B Insider - 2010 Issue 36

Reader Questions: Document Vitals Even If Not Required

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

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