Gastroenterology Coding Alert

Question: When a patient comes in for an injection, can we report a separate E/M service? Ohio Subscriber Answer: It depends on physician presence and what, if anything, was done in addition to the injection.

Let's say an established patient with anemia comes in for a routine B-12 injection. The nurse simply administers the B-12 and performs no other form of monitoring or E/M service. Code 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular). If, however, the nurse spends 5 minutes consulting with the patient about her injection schedule and then administers the B-12, you can report: 90782
99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of the physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached to show that the E/M service was separate from the injection. Warning: If the gastroenterologist is not physically in the office at the time of service, you cannot bill a separate E/M for a nurse-administered injection. He needn't be in the room with the patient and the nurse, but he does have to be somewhere on-site.