Otolaryngology Coding Alert

Remember: The ‘nurse’s code’ was slightly changed last year.

In particular, when a nurse gives an injection in an otolaryngologist’s office, the coding world isn’t always so black and white about how to report the visit. Use these expert tips to determine when you can 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 or other qualified health care professional. Usually, the presenting problem(s) are minimal) during a visit where the nurse administers an injection and what documentation you need to support that claim.

Was It an Office Visit — or Just an Injection?

The main obstacle to correct coding for nurse-administered injections is knowing whether the nurse and the otolaryngologist met the parameters for reporting 99211.

A patient visiting the office and seeing your nurse does not always translate to a 99211 code on the claim. If the office visit is conducted solely for the purpose of injection administration, you can’t typically report 99211.

If the nurse is going to bill for the office visit, they have to monitor the patient before or after the injection. An example of “monitoring” would be checking the patient’s blood pressure, monitoring other vital signs, or observing the patient for any post-injection reactions.

Consider this example: An established patient visits the office to receive a flu shot for the season. The nurse administers the injection and has little verbal interaction with the patient outside of small talk concerning the weather, current events, etc., and counseling the patient on the possible side effects of the vaccination. The otolaryngologist ordered the flu vaccination and told the nurse to administer the vaccination but did not instruct them to do anything else.

Although this may seem like an established patient office visit, the visit actually does not meet the criteria for 99211, and only the injection code should be reported. When the nurse does nothing but administer an injection, the visit must be billed using the appropriate injection code, such as 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)) and for the vaccine, 90630 (Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use).

You can’t report both: The National Correct Coding Initiative (NCCI) bundles 99211 and 90471 together, noting, “Code 99211 is a column 2 code for 96372. You may override the edit when the appropriate modifier applies.” Therefore, there may be situations when the nurse may provide care for the patient, which would qualify the 99211 for a 25 modifier (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 override the NCCI edit.

An example when this may happen might be when the nurse administers the flu vaccine and the patient has some questions about allergy-proofing their home and where to get bedding cases to protect themselves from dust mites. The occurrence of 99211-25 with a vaccine or other nurse-administered service would be rare, and the documentation would need to support the significant and separately identifiable E/M service in order to code 99211 with the vaccine administration.

Keep in mind that each office has its own coding challenges when deciding if an office visit is allowably billed. Keeping the lines of communication open between doctors, nurses, and coders will allow your practice to avoid entanglements when it’s time to bill the payer.

Physician’s Presence Is Required

In order to bill 99211 for nurse visits and other incident-to services such as allergy shots, vaccinations, etc., a physician must physically be in the office suite at the time of the service. They don’t necessarily have to be the patient’s physician and they do not have to be right by the nurse’s side, but they have to be somewhere in the building, and immediately available if the nurse needs them to present to the examination room. Keep in mind that you should report 99211 and other incident-to services performed by nurses only for established patients — never new patients. This code is only for established patients because it is technically performed incident-to, meaning the ancillary staff nurse will be using the supervising provider’s billing information who is present in the office suite in order to get the practice paid for the work.

To meet the guidelines associated with incident-to, the patient must have a plan of care that has already been created by a supervising provider. The nurse would be providing services directly indicated and/or appropriate to the plan of care.

Get the scoop: Incident-to, in relation to the 99211 service, means that a provider (the nurse practitioner [NP], physician assistant [PA], physician, etc.) previously saw a patient, and the patient is returning for a specific service based upon the treatment plan developed that previous visit.