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96372 without physician supervision

  1. #1
    Default 96372 without physician supervision
    Medical Coding Books
    Per cpt, if there is no physician supervision, should report 99211. What specific documentation should the nurses note.

    We have a therupeutic injection tab in our ehr which they document name of medicine, dosage, route, site given, lot number, ndc and expiration date.

    Do they need to make a separate note in progress notes?

    Thanks for your help.

  2. #2
    Midtown OKC
    I am not sure if this helps at all but I attended a Medicare seminar a couple of months ago and had asked the speakers a similar question. We have a patient that receives procrit injections weekly and had been told by their reps that we were to always use 99211 to bill for these visits but that didn't seem accurate. I asked the speakers their opinion and they didn't really give me a straightforward answer until a doctor that happened to be attending the seminar as well stood up and said as long as it is documented that the pt. was there for XX minutes and had no reaction to the medication-the 99211 would be appropriate. The speakers agreed. However, this does not mean that every payer agrees. We all know how that goes.
    Liz H., CPC

  3. #3
    We also document vitals and reaction (if any). Can also add questions answered or information given to patient.

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