Eli's Rehab Report

Question: When our nurse gives injections to patients, we normally bill CPT 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) but our new billing clerk says we should be billing the appropriate injection code (e.g., 90782, therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) because the nurse isnt performing a full E/M. She says that all aspects of an E/M service must be present to bill 99211. Is this correct?

Kansas Subscriber

Answer: There are several answers to your question. First, the descriptor in CPT 2001 for 99211 indicates that normally about five minutes are spent with the patient, and that the history, examination and medical decision-making portions are not required during the visit, as they are for most other E/M codes. So, those aspects of the E/M code would not be necessary if your nurse chose to bill 99211 for an injection. In addition, Appendix D of CPT 2001 lists a clinical example for 99211 as office visit for an 82-year-old female, established patient, for a monthly B12 injection with documented vitamin B12 deficiency. So CPT recognizes that injections are often billed as 99211.

In addition, registered nurses are not able to bill the injection codes (although nurse practitioners can bill the procedure codes as incident to as long as the incident to requirements are met). So if your nurse is an RN, you would not be able to bill his or her services using 90782, and must bill using 99211. However, the Medicare Carriers Manual section 15502 states, CPT code 99211 cannot be used to report a visit solely for the purpose of receiving an injection which meets the definition of CPT codes 90782, 90783, 90784 or 90788. So, even though CPT offers the billing of 99211 for injections as a clinical example, Medicare does not always agree. The answer to whether 99211 can be billed for injections depends largely on which Medicare carrier you use.

Some local carriers have stated that they will not reimburse for any E/M service provided by a nurse when a physician does not see the patient. For example, a March 1997 Blue Cross and Blue Shield of Alabama (that states Medicare Part B carrier) bulletin stated, although the CPT book specifies that office visit code 99211 may be used for visits that may not require the presence of a physician, a physician should not bill for an office visit if only the assistant or nurse actually sees the patient. This is true whether or not the physician is in the office at the time.

Because HCFA has not issued a national policy or guidance on this topic, you should ask your local Medicare carrier and private insurers how they recommend you code for nurse injections.