Gastroenterology Coding Alert

When a nurse gives an injection in a gastroenterologist's office, the coding world isn't always so black and white. Use these expert tips to determine when you can report 99211 for a nurse-administered 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 an established patient, that may not require the presence of a physician).

A patient physically visiting the office 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 report 99211.
 
"If the nurse is going to bill for the office visit, she has to monitor the patient before or after the injection," says Susan Gruber, CPC, of the office of Robert J. Trace Jr., MD, in Hagerstown, Md. An example of "monitoring" would be checking the patient's blood pressure, monitoring other vital signs, or observing the patient for any postinjection 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 the injection, the visit must be billed 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular).

Physician's Presence Is Required

Keep in mind that in order to bill a separate E/M service for a nurse-administered injection, the physician must physically be in the office at the time of the service. 
 
"He doesn't necessarily have to be right by the nurse's side, but he has to be somewhere in the building," says Stephanie Goodfellow, billing supervisor at Mid-America Gastrointestinal Consultants in Kansas City, Mo.
Pinpoint Separately Identifiable Services
 
Goodfellow, whose office routinely performs various infusions and Remicade injections, says that most nurse-administered injections at her practice wind up being office visits as well.
 
"When they [patients] come in the office for an injection, they usually have a question for the nurse about their medication or the injection itself," Goodfellow says. As long as the patient and the nurse engage in some sort of consultation - and it is properly documented - you can report both the office visit and the injection.
 
Gruber, on the other hand, says nurses at her practice often administer B-12 injections that usually require little in terms of nurse consultation. "If the nurse is giving the injection and she's not monitoring the patient, we'll just use 90782," she says.
 
These examples make one thing clear: 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.
 
Consider this example: An established patient with anemia visits the office for a checkup on her condition. The physician is not present for any part of this service, but instructs the nurse (in writing) to administer an injection of B-12 should the patient require it. Upon completion of the observation, the nurse decides to administer a B-12 injection.
 
In this case, the physician left specific instructions for the nurse to consult with the patient about her condition and give the injection only if it was needed. The purpose of the office visit was not solely to receive the injection, so you can consider the injection and consultation separately identifiable. Use 90872 for the injection and 99211 for the office visit, appended with modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the other procedure or other service).

Ask Key Questions to Cover Your Bases

You have to be sure you have sufficient documentation before submitting claims for your nurse's injection services and corresponding office visits. Some less-than-scrupulous payees have tried to report office visits and injections separately without the necessary documentation - piquing carriers' suspicion.
 
When considering whether to separately report an office visit and an injection, ask yourself these questions: