Pediatric Coding Alert

Question: One of our patients was on his way to have an MRI at the hospital. His mother stopped by our office and asked if her son could get a shot of "something" to help calm his nerves. The nurse administered an injection of Diazepam; the patient did not see the physician. Can we bill the injection in addition to an E/M service? What diagnosis would apply? Answer: If the nurse provided an evaluation and management of the patient in addition to administering the Diazepam injection, then begin by coding an appropriate E/M service. In this scenario, the most likely E/M code is 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician ...), since the patient did not see the physician. Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician [...]