Gastroenterology Coding Alert

Question: A patient was seen by one of our medical assistants and given an injection for pegylated interferon. Can I bill for the office visit and the injection together?

Mississippi Subscriber

Answer: The codes you are allowed to report depend on services performed during the office visit. There are two possible circumstances:

1.The medical assistant sees an established patient for a routine follow-up for hepatitis C treatment. The assistant performs several tasks during the visit, including taking an interval history, reviewing labs, making medicine adjustments, discussing social issues, and counseling the patient. The assistant then administers an injection.

In this case, you can code separately for the office visit and the injection because you saw the patient for reasons other than simply administering an injection. Report the office visit with the established patient code (99211-99215) that corresponds to the appropriate level of office care if (and only if) the physician sees the patient and if the note documents the physician's review of the history.

Separately code for the injection by using 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections]; one vaccine [single or combination vaccine/toxoid]). You can also code for the supply of the drug. An example is J9212 (Injection, interferon Alfacon-1, recombinant, 1 mcg). Regarding reimbursement, it helps to report a separate diagnosis code for the office visit and the injection.

2. An established patient comes into the office solely for an injection. The medical assistant sees the patient and administers the injection, performing few or no separate services during the visit. In this case, you can only code for the injection and the supply of the drug.

Remember that when a nurse performs the services, you can code for a 99211-level visit only. Other certified assistants (physician assistants and nurse practitioners) may be able to perform more in-depth evaluations, which could warrant a higher-level office visit code (99212-99215).

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Linda Parks, MA, CPC, CCP, lead coder at Atlanta Gastroenterology Associates; and Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel.