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If a patient declines an injection - can you bill for the cost of the medication?
Question: A patient saw the physician and it was decided that she would get an injection of Stadol. Stadol was drawn up. Right before the injection was to be given, the patient declined. This medication had to be wasted and could not be reused since it is a controlled substance. Would you still bill this?
Answer: The real answer is to check with the payer. My opinion is that you would bill the J-code for the supply, not the administration. This one may cause you some trouble.
Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at firstname.lastname@example.org or email@example.com.
This question originally appeared in the March 2010 issue of Physicians Practice.