Gastroenterology Coding Alert

Injections of interferon are often a gastroenterologists treatment of choice for patients with hepatitis C, an illness that the Centers for Disease Control and Prevention estimates now strikes 30,000 Americans each year. To keep down the cost of this expensive drug, many insurance companies require that it be sent directly to the patient, who must then learn to self-inject him- or herself with it.

All of our hepatitis patients have to pre-certify with their insurance company and are sent the drug directly, according to Dolores Lash, the business manager of Gastroenterology Ltd. in Cherry Hill, NJ.

The gastroenterologist is still responsible, however, for making sure that patient knows how and when to administer the injections. There are also possible side effects to the drug about which the patient needs to know. The procedure for providing instruction varies from practice to practice. In a telephone survey of Gastroenterology Coding Alert subscribers, some indicated that their patients were sent to a special class on injections taught at a hospital or large medical center. Most survey respondents said, however, that the patient is given some educational materials or videotapes and then the gastroenterologist provides further instruction or assigns that task to one of the nurses on staff.

Six weeks before treatment begins, the patient is given a kit from the pharmaceutical company that contains a video and other literature, said Linda Ciccone, the office manager of Westchester Gastroenterology Associates in North Tarrytown, NY, which has three gastroenterologists on staff. The patient then returns to the office for further instruction and his or her first injection.

Level One Office Visit with Nurse

When a nurse is selected to give most of the instruction, gastroenterologists can still bill for a level one office visit (99211, established patient office or other outpatient visit)even if they never see the patient that day themselves. The CPT description for that code refers to it as a visit that may not require the presence of a physician. The CPT manual goes on to state that typically, 5 minutes are spent performing or supervising these services.

If that individual is seen by the nurse, who explains the proper technique for the injection, the side effects of the medication and the need for proper follow-up, then the visit can be billed as 99211, said Ron Nelson, PA-C, an advisor to the AMA CPT Advisory Committee and president of Health Services Associates in Fremont, MI.

Reimbursement Levels Vary

A private insurer might pay $20 to $23 in reimburse-
ment for such a visit or might not, depending on the type of insurance the patient has.

While 99211 is the appropriate code for this visit, most managed care plans will not pay additional reimbursement, cautions Garnet Dunston, past secretary of the American Academy of Professional Coders and president of the health-
care consulting firm Dunston Enterprises in Phoenix, AZ.
The injection instruction is probably already covered under
the plans capitation payment, which is a monthly service fee paid on a per-patient basis to physicians by the HMO.

Some PPOs may pay additional reimbursement, she adds. What CPT codes fall under the capitation payment are really carrier specific.