How to Document an Injection

1. Find the injection type (what will populate the CPT code) and diagnosis (what will populate the ICD-10 Code) you are looking for in the list of treatment plans. The second line of the treatment plan title lets you know what these will be. 

2. Select the treatment plan by tapping on it.  

3. Tap on the location on the 3-D Body map to indicate where the procedure was performed. If the location was indicated in the HPI tap on the anatomical location listed on the procedure tag.  

4. After tapping on the body map, a calculator will pop up where you can enter the injection volume. The value can be set in the treatment plan as a default, but if it is different you can manually key it in. 

5. You will know the injection was applied to a location as the procedure tag will change from the anatomical location to the procedure tag.

6. Then if there is any additional information you want to add or edit regarding the details of the injection, tap once on the procedure tag and choose the blade holder icon from the selection wheel.  

7. Tap on the appropriate Procedure and then scroll to the bottom to the Procedure Summary where you will then tap on the "Injection" segment. From here you can add any additional information such as the Lot Number, expiration date, and J-Code.

NOTE: the provider can set the treatment plan up so the J-Code automatically pulls.