Ob-Gyn Coding Alert

Question: When a patient comes in for an injection of DepoProvera or Lupron, and the doctor sees the patient personally to talk to her (but does not actually give the injection), can I still bill 99211? Or, since the doctor was involved, should it be coded as 99212?

Alabama Subscriber

Answer: You can bill 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician ...) if a doctor saw the patient. As to what the physician can bill, it depends on what he or she documented. If the encounter is to counsel the patient, the physician can bill on the basis of time (the number of minutes must be documented in the physicians note), and that will determine the level of evaluation and management (E/M) service he or she may bill. But if the physician bills for an E/M service, he or she may not also bill for the injection using 90782 (therapeutic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) because it is included even if he or she did not personally give the injection. Note also that 99211 describes a minimal service, not an injection procedure. If the nurse gives the injection and the patient is not seen by the physician, 99211 would only be billed when a minimal service has been documented in the record. That service will include more than the dosage and name of drug injected.