Without the proper documentation, injection coding can be confusing at times. For the most part, injections are normally performed in an office setting.

The most common injections can be found in the musculoskeletal section of the American Medical Association’s CPT® 2015 Professional Edition book. Injections are considered surgical which means that reimbursement for the services includes any type of local anesthesia.

When documenting injections, the following should be included:1

  • Drug given
  • Amount of drug given
  • Route (intramuscular, joint, etc)
  • Anatomical site/location (right arm, left arm, etc)
  • Who administered

Injection coding can be very difficult without sufficient documentation. Since injection codes are selected based on the route of administration, it is necessary to know if an injection was done in the joint or intramuscular.

1American Medical Association’s CPT® 2015 Professional Edition. Pages 100-101.

Author - Female

About the author

Lori Johnson, CPC, CPMA of Compliance—Academic, Multi-specialty and Office-based Medicine, McKesson Business Performance Services.