Ob-Gyn Coding Alert

Reader Questions:

Billing for a Low-level E/M

Question: When can the E/M code 99211 be correctly used in conjunction with an injection? Consider a typical injection coded with 99211, J1000 and 90782. The patient did not see the physician. Is this correct coding?

Jeanne McMillen, Gyn-Ob P.C.
Memphis, TN

Answer: The code 99211 does imply a service rendered by a healthcare professional other than the physician. The CPT says it is a service that may not require the presence of a physician. But billing this code does require some chart documentation. In general, you can code for an injection using 99211 plus the J1000 (or other code that represents the drug that was injected), or you can bill the injection procedure (90782), plus the J code for the drug used. But you should not bill for all three codes, unless something beyond the injection was done to the patient to justify both a 99211 and 90782.

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