Gastroenterology Coding Alert

Answer: Vitamin B12, iron and interferon are just a few of the medications injected into patients by gastrointestinal nurses. There are two CPT codes that can be used90782 (therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) or 99211 (established patient office or other outpatient visit), also referred to as the non-physicians code because it does not require a gastroenterologist to be present in the room.

Because code 99211 has a relative value unit (RVU) of 0.55 versus 0.12 for 90782, most gastroenterologists will prefer to use 99211. There is some disagreement, however, between CPT and Medicare regarding when it is appropriate to use the higher valued 99211.

According to CPT, 99211 is appropriate when the nurse administers only an injection. An office visit for a 73-year-old female, established patient, with pernicious anemia for weekly B12 injection is one of the CPT clinical examples for this code.

Medicare has several documentation requirements, which must be met before code 99211 can be used:

- The patients record needs to show medical necessity. A standing order to give the injection is not enough. The nurse needs to be evaluating the patient for a specific problem.

- The gastroenterologists involvement must be shown. Although the gastroenterologist does not see the patient for a 99211 visit, the documentation needs to indicate that he or she provide some direction to the nurses service.

- The nurse needs to fully document the office visit and have the gastroenterologist sign off on it. The lot number of the medication and the site where the injection is given are not enough.

Clearly there are two sets of rules on this, says Pat Stout, CMT, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn. The clinical examples state that you can use code 99211 to report the administration of an injection, even one that is administered on a weekly basis. Medicare has a more stringent set of requirements. In the end, the payer has discretion over which code it is willing to reimburse.

Stout suggests that gastroenterologists contact their local Medicare and private insurance payers to obtain specific instructions on how to code for this service.