Ob-Gyn Coding Alert

If the ob-gyn isn't present, revert to a nurse visit, CPT says

CPT 2006 injection administration coding instructions require you to verify the ob-gyn's involvement to report 90772 or to submit the nonphysician-performed procedure as 99211 -- or depending on payers- incident-to policies -- possibly a no-charge.

To determine which code applies, ask yourself the following questions:

1. Is the Doctor in the Office and Available During the Injection?

If you can answer, -Yes, the ob-gyn provided direct supervision throughout the subcutaneous or intramuscular injection,- you can report 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). CPT adds this requirement in an instruction following 90772 that indicates you should -not report 90772 for injections given without direct physician supervision.-

If the injection administration encounter does not meet the direct-supervision criteria, you should instead 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 ...), according to CPT's instructions following 90772. -CPT's direct- supervision example is consistent with CMS- direct- supervision guidelines as defined in the Medicare Carriers Manual 2050.1,- says Quinten A. Buechner, MS, MDiv, CPC, president of ProActive Consultants LLC in Cumberland, Wis.

Translation: The physician must be in the office setting and immediately available. The requirement does not mean the ob-gyn must be present in the exam room during the procedure to bill 90772.

-This level is higher than the general-supervision requirement [physician available by phone] that therapeutic shots required in 2005,- Buechner says.

2. Does Documentation Support the MD's Presence?

Without supporting documentation that shows the ob-gyn was in the office and immediately available, you should consider coding a nurse visit instead of an injection administration. Remember: The direct supervising ob-gyn does not have to be the physician who created the standing order. But to avoid reporting 90772 incorrectly, make sure documentation can prove the physician's presence.

Best practice: -Have a stamp made that indicates -Direct supervision by,- - says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. The nurse can then write which ob-gyn was present during the injection administration. If Medicaid or another insurer requests documentation supporting direct supervision or audits your 90772 claims, the chart note will substantiate your charge.

The scheduling record should also show which ob-gyn was present in the office suite during the injection administration.

3. Does the Insurer Allow 99211 With Lower-Level Supervision?

When an ob-gyn provides injection administration under general supervision, you should report 99211 instead of 90772 if the procedure meets your payers- incident-to rules. -You should check a company's incident-to rules before using 99211 without direct physician supervision,- Cobuzzi says.

Example: The patient presents for her monthly Depo-Provera injection for contraception, which a nurse administers. The ob-gyn, who is the sole ob-gyn of his practice, is at the hospital delivering a baby.

In this situation, you should use 99211 instead of 90772, according to CPT rules. The procedure does not meet the direct-supervision requirement because the physician is not present in the office suite.

But CPT's 99211 directive could contradict insurers- incident-to requirements. -Although some payers follow CPT's more liberal rules and allow 99211 without direct supervision, CMS requires the physician provide direct supervision to bill a service incident-to,- Cobuzzi says.

The lowdown: Reporting 99211 for the above Depo-Provera injection scenario hinges on the insurer's incident-to requirements. If the payer follows Medicare policies, -you should treat the injection as a no-charge service,- Cobuzzi says. You would code neither 90772 nor 99211. If your office provides the Depo-Provera, assign J1055 (Injection, medroxyprogesterone acetate for contraceptive use, 150 mg).