Pediatric Coding Alert

Revert to a nurse visit in absence of direct supervision, CPT states

CPT 2006 injection administration coding instructions require you to verify the pediatrician's involvement or to downcode the nonphysician-performed procedure from 90772 to CPT 99211 --or depending on insurers' incident-to policies--possibly a no charge.

To determine which code applies, make these inquiries.

1. Is Doctor in Office and Available During Injection?

If you can answer, "Yes, the pediatrician 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 pediatrician must be present in the exam room during the procedure to bill for 90772, Buechner says. "This level is higher than the general supervision requirement [physician available by phone] that therapeutic shots require in 2005."

2. Does Documentation Support MD's Presence?

Without supporting documentation that shows the pediatrician was in the office and immediately available, you should consider coding a nurse visit instead of an injection administration. Remember: The direct supervising pediatrician 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 pediatrician 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 pediatrician was present in the office suite during the injection administration.

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

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

Example: A parent brings her baby in for her fifth Synagis treatment, which a nurse administers. The pediatrician is at the hospital making rounds.

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 Synagis 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 immune globulin, assign 90378 (Respiratory syncytial virus immune globulin [RSV-IgIM], for intramuscular use, 50 mg, each).