Gastroenterology Coding Alert

NPPs can get paid for teaching patients to self-inject--here's how

You have a number of options when coding interferon injections for hepatitis C patients, depending on the circumstances under which the injection occurs. You might report any combination of the injection, the supplies and an E/M service. Here are four scenarios to show you how to make the most of these visits.

Case 1: -Injection Only- Calls for 90772

In the rare case when a patient comes to your office for an interferon injection only, you would report the injection administration code and--if your office also supplied the drug--the medication code.
 
Be aware of a change: For both private and Medicare payers, the correct injection administration code is 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). This is a change from 2005, when Medicare payers required G0351 (Therapeutic or diagnostic injection) for interferon injections.

Don't miss out on supplies: If the practice provides the drug, you may also report the level II code J9212 (Injection, interferon alfacon-1, recombinant, 1 mcg) from the chemo-therapy drugs section of HCPCS.

Case 2: Separate E/M Is OK for Follow-Up

Often, office personal other than the physician will handle follow-up care for hepatitis C patients. In such cases, you can still report an E/M code for the nonphysician practitioner's (NPP-s) effort, but you must document the service just as carefully as if the physician provided the care.

A typical follow-up visit might consist of a medical exam, lab reviews, medication adjustments, monitoring of side effects, an investigation of social issues and depression issues, and education on medication administration, says Amy Walker, CPC, insurance and billing supervisor at Gastrointestinal Associates in Knoxville, Tenn.

Depending on your local regulations and scope-of-practice laws, NPPs can often perform these duties, says Quinten A. Buechner, MS, MDiv, ACS-FP/GI/PEDS, CPC, president of ProActive Consultants LLC in Cumberland, Wis.

Most coders bill a level-one established patient office visit (99211) for NPP services of this type. These visits may not require the presence of a physician, usually take about five minutes, and deal with presenting problems that are minimal. Again, depending on your local guidelines, you may usually report these services incident-to in the office setting.

Don't -overcode-: You should never report 99211 with the injection code (90772) unless the NPP provided separate, identifiable services in addition to the injection, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, an AAPC National Advisory Board member and president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. If the patient comes in solely to receive the shot, and the nurse only asks the patient how he is doing, you should not report a separate E/M.

If, on the other hand, the nurse observes the patient for a reaction or takes vitals, you could bill for a separate office visit with 99211. You should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M to differentiate it from the -inherent- E/M component of 90772.

Warning: Code 99211 is under scrutiny from many carriers, so your documentation must indicate why the visit is significant and separate, either with a different diagnosis code or by describing the office visit thoroughly.

Case 3: E/M Is OK for Self-Injection Instructions

Services that count as counseling and/or coordination of care can also provide E/M billing opportunities. For example, NPPs in gastro offices also fill another important role: teaching hepatitis C patients how to inject interferon at home. To keep down costs, many insurance companies require that the drug be sent directly to the patient, who must then learn to self-inject himself with it.

NPPs don't normally inject patients with interferon, but rather teach hepatitis patients to self-inject, Walker says. -If the patient cannot be taught to self-inject, then we request that a family member be present so that they can be taught to do the injection,- she says.

Example: -Because our nurse practitioner handles all the hepatitis C patients for teaching, we code by time,- Walker says. -The NP is very well trained in charting start and stop times. We can often justify a level-three visit (such as 99213) that consists of teaching a patient to inject, discussing side effects of drugs, labs results, follow-up visits, and additional counseling.-

Case 4: If Patient Brings Drug, Don't Bill It

If the nurse provides an injection, but the patient brings in his own medications, you cannot bill for the drug supply, only for the administration.

Example: A hepatitis C patient brings in a supply of interferon for injection by the nurse. The nurse performs limited E/M services, including taking vitals and counseling the patient. You would code 99211-25 for the E/M and 90772 for the administration of the drug. Do not code for the supply.