Gastroenterology Coding Alert

Question: Our gastroenterologists take care of the initial hepatitis visit and counseling. Our GI nurses take care of the follow-up counseling, injections and training. Can we get reimbursed for the nursing visits? How should we bill? Should the nursing notes be signed by the nurse?

Hepatitis patients have to schedule regular office visits, due to the nature of the disease and treatment. Often, office personnel other than the physician take over for most of the follow-up care. Atypical visit consists 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 Teresa L. Baker, CPC, physician billing manager for the Gastroenterology Division at the University of Michigan. Depending on your local regulations, nurses can perform some of these duties, such as counseling and administering injections.

Most coders bill a level-one established patient office visit (99211) for nurse services. These visits do not require the presence of a physician, usually take about five minutes, and deal with presenting problems that are minimal. Baker says that these visits are billed incident-to in the office setting.

With certain medications, such as interferon, many insurance companies require the drug be sent directly to the patient for administration. These patients will have to receive education and instruction at the physician's office. Anurse usually performs these services. Even when the bulk of the visit is education or instruction, you should still bill 99211.

Problems arise when a patient comes in for an injection. According to Linda Parks, MA, CPC, CCP, coding specialist at GI Diagnostics Endoscopy Center in Marietta, Ga., you should code for the injection only when the nurse doesn't do anything else that would constitute an additional E/M service, such as taking blood pressure and weight, and counseling. But suppose a patient comes in and sees a nurse. The nurse takes his blood pressure and weight, administers an interferon injection, and observes the patient's response to the injection. In this scenario, you would code 99211-25, 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) and J9212 (Injection, interferon Alfacon-1, recombinant, 1 mcg). Make sure to append modifier -25 onto the E/M code to show that the services were separate and identifiable.

For nurse-only visits, the physician does not have to review the chart and co-sign, Baker says. This corresponds to the CPT definition that this service does not require the presence of a physician. Therefore, the nurse's signature will suffice.

According to Medicare's 2003 National Physician Fee Schedule, you should expect about $20 for this nurse-only visit (99211). Private insurers may pay from $20 to $23 in reimbursement.