Gastroenterology Coding Alert

E/M and injection claim must prove nurse provided separate service

Reporting nurse injections with a separate E/M service was always tricky, but the prospect is even more challenging for gastroenterology coders in 2005.

Why? To file a successful claim for a nurse injection with E/M service this year, you'll still have to follow the same old rules about coding nurse injections, meaning you have to prove the physician ordered the E/M service and that the nurse provided a service separate from the actual injection. But you'll also have to contend with Medicare's new G codes for injections, which override the CPT codes for all Medicare carriers.

The path to successful nurse visit coding is a little more intricate this year, but you can follow it to pay dirt using these steps. Determine if Nurse Provided Separate Service Despite warnings of denials, there are still gastroenterology offices that file an E/M service and injection code every time a nurse gives an injection. This is extraordinarily bad practice, says Kristine Eckis, CPC, CMM, president of Bottom Line Medical Administrative Consultants Inc. in Lake Wales, Fla. 

"I found that nurse visits are somewhat abused in some practices. Anytime you have a service performed by the nurse and she bills for it, it must have been under the direction of the physician, and he must have documented it in the medical record," Eckis says.

Example: An established patient with anemia reports to the office for a monthly B-12 injection.

Noting the gastroenterologist's request in the patient file, the nurse checks with the patient about her reactions to the shots and discusses scaling back to B-12 injections quarterly. The nurse then injects the patient with B-12, and the entire visit takes six minutes.

In this instance, the nurse provided an E/M service in addition to the injection, so you can report two codes.

When filing with a private payer, you should:
  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) for the E/M visit.
  attach modifier 25 (Significant, separately identi- fiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99211 to show that the E/M service was separate from the injection.
  include documentation explaining what the nurse discussed with the patient during the E/M time.
  report 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcut-aneous or intramuscular) for the injection. Medicare exception: You should not file the same claim for your Medicare carriers this year.

When filing injections with a Medicare carrier, you need to remember that Medicare is running a demonstration project in 2005 that dictates that you should [...]