Gastroenterology Coding Alert

Question: I work as a clinical nursing specialist in the endoscopy department of a community hospital, and we would like to begin teaching the hepatitis C patients how to give injections and to manage side effects. This would be done one-on-onenot in a group setting. Do you know if reimbursement is available? Weve been informed that code 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) is for a physicians office, not a hospital setting. Do you know of another code that is appropriate?

Susan Ruel, RN, MSN, CGRN
Grand Rapids, Mich.

Answer: In Instruction on Interferon Injections by Nursing Staff May Be Eligible for Reimbursement (October 1999 Gastroenterology Coding Alert, p. 14), it was reported that reimbursement may be available when a nurse administers a patients first interferon injection and provides information on the proper technique for injection, the side effects of the medication and the need for follow-up. The recommended billing code was 99211, which stipulates that the session may not require the presence of a physician in the room. That code can be used in an office setting, in an outpatient or other ambulatory facility.

As a hospital employee, however, you are not eligible to bill for a separate evaluation and management (E/M) service, according to Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. The hospital might be able to receive some reimbursement as part of a facility fee.

If you are not a hospital employee, then you might be able to bill Medicare under your own provider number. Some states permit advanced nurse practitioners (registered nurses with an MSN and certifications) to work independently, says Lou Ann Schraffenburg, MBA, RRA, CCS, clinical data manager for Advocate Health Care in Chicago and chair-elect of the Society for Clinical Coding. If state regulations allow for it, then these advanced practice nurses can work independently of a physician and may be able to bill separately for E/M sessions.

Regarding whether these codes can be used in your hospital setting, CPT states that codes 99211-99215 can be used to report E/M services in the physicians office or in an outpatient or other ambulatory facility. A patient is considered an outpatient until inpatient admission to a health care facility occurs.

Although hepatitis C is now a serious health problem, reimbursement for certain services such as these patient education sessions is going to vary significantly from state to state and between private payers and Medicare. The only way to be certain about the payment available and the specific coding requirements is to contact your local payers and state medical director for advice.