Ob-Gyn Coding Alert

CPT^® guidelines focus on whether the ob-gyn is present. Here’s why.

When you get ready to report an injection administration code, you need to pause to examine the situation. Depending on your payers’ incident-to policies, you may be facing a no-charge situation.

To determine when — and if — you should apply a code for this procedure, 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 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). CPT^®  gives an instruction following 96372 that indicates you should “not report 96372 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 96372. CPT^®’s direct supervision example is consistent with CMS’ direct supervision guidelines as defined in the Medicare Carriers Manual 2050.1 (Incident to Physician’s Professional Services).

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 96372.

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 96372 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, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare Solutions in Tinton Falls, New Jersey. 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 96372 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 96372 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 96372, 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 96372 nor 99211. If your office provides the Depo-Provera, assign J1050 (injection, medroxyprogesterone acetate, 1 mg) with a quantity of 150 for the contraceptive dose.