Internal Medicine Coding Alert

Question: A patient with testosterone deficiency comes to our office for injections. After a few visits, our nurse showed him how to administer the testosterone injection himself. Can we submit the nurse's time as an education visit?

Maine Subscriber

Answer: You have two choices for reporting the nurse's time and patient education.

Option 1: Submit 98960 (Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient [could include caregiver/family] each 30 minutes; individual patient). Verify that the nurse used some type of curriculum and that she spent at least 30 minutes with the patient.

Option 2: Submit 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician ...). You'll turn to 99211 if the service and documentation don't support 98960.

Also include an appropriate diagnosis for the visit, such as 257.2 (Testicular dysfunction; other testicular hypofunction).