Low-level E/M Defines Self-Injection Training

By G. John Verhovshek, MA, CPC

Erika Heiges, MPH, CHES, senior health educator with HealthEd in Clark, NJ recently asked Coding Edge, “Which CPT® code is appropriate when a provider instructs a patient how to inject a self-administered drug?”

Evaluation and Management – CEMC

Self-injection Training is…

Self-injection training often is provided by a non-physician practitioner (NPP), and includes educating patients on injection procedures, possible side effects, and other pertinent information. Face-to-face dialogue, classes, and/or video recordings may be used to provide instruction.

“Patients that may require self-injection training include those with chronic disease, such as rheumatoid arthritis—Humira and Enbrel are the drugs for these patients,” notes Linda Martien, CPC, CPC-H, RCM education specialist at National Healing, Inc. Additional conditions that may require self-injection training include relapsing-remitting multiple sclerosis, hepatitis, erectile dysfunction, psoriasis, and migraine headaches, among others.

Report the Who, What, and Where

“Code selection for self-injection training will depend on who is providing the service, and in what setting,” adds Nancy L. Reading, RN, BS, CPC, of Cedar Edge Medical Coding and Reimbursement. “An office nurse would be most likely to provide this service, although the provider would have to be in suite at the time. These are incident-to services, and you’d have to report 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.

“From my understanding, when the self-injection training is provided by staff under the supervision of a credentialed provider, rather than by the credentialed provider, the only coding option would be 99211,” confirms Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, with MJH Consulting.

Note that self-injection training sessions may far exceed the typical 5 minute reference time for 99211. The practice simply has to absorb the cost of the NPP’s additional time.

Be aware of scope-of-practice issues when an NPP provides patient services. “In some states, for instance, an MA [medical assistant] must pass additional certification exams to be able to give injectables. So they may not always be the personnel to train,” Reading continues. Research the scope-of-practice guidelines in your state to verify that the NPPs in your practice are providing and reporting services appropriately.

Reading warns, “This issue really begs the incident-to criteria if self-injection training is done in place of service 11 [Office]. All other POS [place of service] would not bill or code for this service for Medicare Part B because the staff is not the physician’s and the physician is seldom the person doing the training. An in-depth analysis of where the service is performed and who owns the clinic and pays the staff is essential to determine prior to even discussing the service.”

In the Event of a Shared Visit

Occasionally, injection training in the office may be part of a shared visit, in which the NPP provides the injection training and the physician sees the patient for additional, medically-necessary evaluation. This, too, is an incident-to service, for which the physician may report an appropriate evaluation and management (E/M) service level for the total work. The Medicare Claims Processing Manual, section 30.6.1.B, explains, “When an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS, or CNM [nurse practitioner, physician assistant, clinical nurse specialist or certified nurse midwife]), the service [in POS 11] is considered to have been performed ‘incident to’ if the requirements for ‘incident to’ are met and the patient is an established patient. If ‘incident to’ requirements are not met for the shared/split E/M service, the service must be billed under the NPP’s UPIN/PIN [Unique Physician Identification Number/Provider Identification Number], and payment will be made at the appropriate physician fee schedule payment.”

In a hospital setting, when an E/M is shared between a physician and an NPP from the same group practice, and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician’s or the NPP’s UPIN/PIN number.

Document Each Encounter

In all cases, “documentation of patient education would be necessary,” Reading says. “As well, I would recommend documentation of a return demonstration. This is crucial to ensure that the patient really can self-inject. You also might want to document support systems at home, such as a medical alert bracelet, in case the patient gets into trouble.”

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