Gastroenterology Coding Alert

Tip: Yes, you do need thorough documentation when reporting 99211.

Your nurses provide vital services to your patients, and their claims can be vital to your income. Submitting claims for nurses’ services should get just as much attention as the gastroenterologists’ claims do, but in some practices, that’s not happening.

When a nurse gives an injection in a gastroenterologist’s office, the coding world isn’t always so black and white about how to report the visit. Use these expert tips to determine when you can report 99211 during a visit when the nurse administers an injection and what documen­tation you need to support that claim.

Was It an Office Visit — or Just an Injection?

The main obstacle to correct coding for nurse-administered injections is knowing whether the nurse and the gastroenterologist met the parameters for reporting 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional…).

A patient physically visiting the office and seeing your nurse does not always translate to a 99211 code on the bill. If the office visit is conducted solely for the purpose of injection administration, you can’t typically report 99211.

If the nurse is going to bill for the office visit, they have to monitor the patient before or after the injection. An example of “monitoring” would be checking the patient’s blood pressure, monitoring other vital signs, or observing the patient for any post-injection reactions.

Consider this example: An established patient with anemia visits the office to receive a vitamin B-12 injection. The nurse administers the injection and has little verbal interaction with the patient outside of small talk concerning the weather, current events, etc. The gastroenterologist told the nurse to administer the injection but did not instruct her to do anything else.

Although this may seem like an established patient office visit, the visit actually does not meet the criteria for 99211, and only the injection code should be reported. When the nurse does nothing but administer an injection, the visit must be billed using the appropriate injection code, such as 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular).

You can’t report both: The National Correct Coding Initiative (NCCI) bars you from reporting 99211 and 96372 together, noting, “Code 99211 is a column 2 code for 96372. You may not override the edit.” Therefore, there are no circumstances when you can report both codes together, even if you append a modifier. However, in the outpatient setting, 99211 actually pays $23.07, whereas 96372 reimburses just $16.94, so that’s why many practices prefer to bill 99211 on the claim rather than 96372 — it translates into about six dollars more per submission.

Keep in mind that each office has its own coding challenges when deciding if an office visit is allowably billed. Keeping the lines of communication open between doctors, nurses, and coders will allow your practice to avoid entanglements when it’s time to bill the payer.

Physician’s Presence Is Required

In order to bill 99211 for nurse visits, the physician must physically be in the office at the time of the service. They don’t necessarily have to be right by the nurse’s side, but they have to be somewhere in the building.

In addition, you should report 99211 only for established patients — never new patients. This code is only for established patients because it is technically performed incident-to, meaning the ancillary staff nurse will be using the supervising provider’s billing information to get the practice paid for the work.

To meet the guidelines associated with incident-to, the patient must have a plan of care that has already been created by a supervising provider. The nurse would be providing services directly indicated and/or appropriate to the plan of care.

Get the scoop: Incident-to, in relation to the 99211 service, means that a provider (the nurse practitioner, physician assistant, physician, etc.) previously saw a patient, and the patient is returning for a specific service based upon the treatment plan developed that previous visit.

Important: If the same physician who provided the original treatment plan is not the supervising physician during the patient’s return visit, the service must be billed under the physician who is supervising the day that the patient returns.

For example: The physician’s treatment plan states that he wants the patient to come back for a blood pressure check and to assess whether he is having problems with his medications. The patient returns to the office, and his blood pressure has improved. Also, his medications are not bothering him. The provider (perhaps the nurse or medical assistant) documents that she saw the patient, took his blood pressure, and he is doing fine with his medications. The provider must report all of this information to the physician. So, although the physician doesn’t have to see the patient, he must receive that information about the encounter from the provider. The 99211 could then be billed under the physician who provided the supervision and was in the office that day.