Pediatric Coding Alert

Question: One of our patients was on his way to have an MRI at the hospital. His mother stopped by our office and asked if her son could get a shot of "something" to help calm his nerves. The nurse administered an injection of Diazepam; the patient did not see the physician. Can we bill the injection in addition to an E/M service? What diagnosis would apply?

Answer: If the nurse provided an evaluation and management of the patient in addition to administering the Diazepam injection, then begin by coding an appropriate E/M service. In this scenario, the most likely E/M code is 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician ...), since the patient did not see the physician.

Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to denote that it was significant and separately identifiable from the injection service.

Next, report the injection code (such as 96372, Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). Finally, report J3360 (Injection, diazepam, up to 5 mg) for the medication.

Your best diagnosis choice is either a non-specific anxiety code, such as 300.00 (Anxiety state, unspecified) or 300.09 (Anxiety state; other), or the general symptom code for nervousness, 799.21 (Signs and symptoms involving emotional state; nervousness).

Document: Because the physician didn't see the patient, verify that he was in the building at the time and wrote an order for the injection. That will help support a billable service according to incident-to rules, where applicable.

The nurse should complete an evaluation and management note to support billing 99211. This should include a history and assessment, including vital signs. Plus in conjunction with the physician, you should document the decision to proceed with the requested injection. The physician should countersign this note.