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In the randomized placebo-controlled HOME trial of 390 adults with type 2 diabetes (de Jager and colleagues, Long term treatment with metformin in patients with type 2 diabetes and risk of vitamin B-12 deficiency, BMJ, 2010), metformin lowered serum B12 by a mean of 19 percent over 4.3 years

Fix: Only bill a separate E/M service when the documentation supports distinct medical decision-making beyond "patient here for injection." Dose adjustments, side effect management, and review of treatment progress all support a separate E/M service, but they must be documented

This distinction is crucial and defines its unique therapeutic potential

I too took a B12 injection and I haven't been able to sleep since