Primary Care Coding Alert

Question: When a patient comes in for a Depo-Provera injection, one of our physicians charges for the injection administration, the Depo-Provera itself and the nurse visit. None of our other providers bill all three. Is this correct ? Michigan Subscriber Answer: Your instincts are right. Medicare says you cannot bill for administration of an injectable medication (90782, Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular]) and a nurse visit (99211, Office or other outpatient visit for the evaluation and management of an established patient, that may or may not require the presence of a physician. Usually the presenting problem[s] are minimal. Typically 5 minutes are spent performing or supervising these services) at the same time. You can either bill the 99211 and the medication (in your case, J1050 or J1055) or bill the injection administration and the medication. Most private payers follow this rule as well.

So which option should you choose? When the nurse evaluates the patient at all (e.g., when giving a Depo-Provera shot, the nurse may need to find out if the patient is pregnant) use 99211. If the nurse just gives an injection, use the injection code.

Missing from the 99211 definition are the history, examination and medical decision-making components that are required of most other E/M codes. Because the CPT manual states that the presence of a physician is not necessary, the code is often used to bill services by a nonphysician practitioner, such as a registered nurse.