Internal Medicine Coding Alert

Question: One of our patients was on his way to have an MRI at the hospital. His daughter (who serves as his primary caretaker) brought him by our office beforehand and asked if he could get a shot of “something” to help calm his nerves. The nurse administered an injection of Diazepam; the patient did not see the physician. Can we bill the injection in addition to an E/M service? What diagnosis would apply?

Illinois Subscriber

Answer: If the nurse provided an evaluation and management of the patient in addition to administering the Diazepam injection, then begin by coding an appropriate E/M service. In this scenario, the only acceptable E/M code is 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician ...), since the patient did not see the physician.

Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code to denote that it was significant and separately identifiable from the injection service.

Next, report the injection code (such as 96372, Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). Finally, include J3360 (Injection, diazepam, up to 5 mg) for the medication.

Your best diagnosis choice is either a non-specific anxiety code, such as 300.00 (Anxiety state, unspecified) or 300.09 (other anxiety states), or the general symptom code for nervousness, 799.21 (nervousness).

Document: Because the physician didn’t see the patient, you should verify that he was in the building at the time and wrote an order for the injection. That will help support a billable service according to incident-to rules, where applicable.

The nurse should complete an evaluation and management note to support billing 99211. This should include a history and assessment, including vital signs. Plus, in conjunction with the physician, you should document the decision to proceed with the requested injection. The physician should countersign this note. Absent such documentation, you are left to report only the injection and the drug code.

Caution:  If the payer is Medicare or any other payer that follows the National Correct Coding Initiative (NCCI) edits, reporting 96372 and 99211 for the same patient on the same date of service will result in denial of the 99211. NCCI designates 99211 as a column 2 code for 96372 and does not permit a modifier to override the edit. Since the Medicare payment allowance for 96372 is higher than that for 99211 anyway, you are best served to report the 96372 code rather than 99211, if forced to choose between the two due to NCCI.