Admin or E/M only if patient self-administers an injectable

jonique.dietzen

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Hello,
I'm wondering if anyone has come across this before and what your opinion is. The nurse taught the patient how to give an injection, then the patient injected it in the office with the nurse supervising.

The note is:
"Teach back method used to instruct pt on self injection with z track. Pt successful with first injection."

Do we charge for an administration or only the office visit? Would your opinion be different if it was a physician supervising instead of a nurse?

Thank you,
Jonique Dietzen, CPC

Note: We are erring on the side of caution and not billing an admin. I'm just wondering how others would handle this situation.
 

thomas7331

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You are correct, this would be considered patient education which falls under the CPT definition of counseling as a component of an E&M service. You would not bill for the injection if the patient is self-administering the medication.
 
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