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Gastroenterology Coding Alert

You Be the Coder:

When Do Services Constitute Separate E/M?

Published on Sat Oct 09, 2004

Question: Our office treats several hepatitis patients who come into the office for interferon injections, and we are in a coding quandary. Sometimes, the nurse's notes indicate that a separate E/M may be reportable in addition to the injection, but we are unsure. When can we report only the injection, and when can we report the injection and the E/M service?

New Mexico Subscriber

Answer: When a hepatitis patient reports to the office for an interferon injection, you may be able to report a separate E/M service. However, the doctor (or nurse) must provide significant, separate service in addition to the injection. Consider these two interferon shot scenarios:

Scenario 1: A hepatitis patient reports for his interferon injection. The nurse gives the patient the shot, makes some small talk about the patient's tolerance of the treatment, smiles and waves goodbye. The nurse does not provide any sort of E/M service, and there is no documentation except the provision of the shot.

In this case, you should report 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) for the injection.

Why? The nurse provided no sort of service outside of administering the interferon shot.

Scenario 2: The same hepatitis patient reports for his interferon injection. The nurse takes the patient's blood pressure and weight, gives the shot, observes the patient's reaction, reviews the patient's treatment side-effects and provides diet advice. In the chart the nurse records giving the shot, the patient's reaction to the shot, and the discussion and advice provided.

In this case, the nurse provided an E/M service that was distinctly separate from the injection. On the claim, you should:

  • report 90782 for the injection.

  • report 99211 (Office or other outpatient visit for   the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) for the E/M service.

  • append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99211.

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