Primary Care Coding Alert

Question: Does CPT's note following 90772 mean that I may report 99211 for a family-physician-ordered Versed injection that a medical assistant administers to a private-pay patient when the FP is available by telephone?


Kansas Subscriber


Answer: CPT's parenthetical note following 90772  (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) does direct you to assign 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...) when staff perform a therapeutic, prophylactic or diagnostic injection without direct physician supervision. But the rule may conflict with the CMS incident-to requirements. Remember: Incident-to is a CMS concept. CPT does not contain any specific incident-to rules. The AMA did not consider the CMS incident-to rules that require direct supervision for 99211.

Nutshell: CPT's note contradicts Medicare guidelines. Medicare does require that a physician provide direct supervision, meaning he must be on-site, to satisfy 99211 incident-to provisions. But for non-Medicare, the AMA is saying direct supervision is not necessary via the note following 90772, which states, -Do not report 90772 for injections given without direct physician supervision. To report, use 99211.-

Some insurers may follow Medicare's lead and also require direct supervision for 99211. Others may have looser policies. When an insurer does not follow CMS- incident-to requirements, you may assign 99211 when staff perform an injection and the FP is not in the office. In these cases, you may consider coding per insurers- rules, rather than universally applying Medicare guidelines.

Strategy: For the above Versed injection scenario, check the insurer's physician-supervision requirements. If the private payer permits billing services provided without direct supervision, report 99211. For insurers that require the physician be in the office to bill a service incident-to, you should not charge the administration. Regardless of injection service coding, report the Versed with J2250 (Injection, midazolam HCl, per 1 mg).

Answers to You Be the Coder and Reader Questions answered/reviewed by Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.; Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City; and Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.