Wiki Doc wants to bill 96372 and 99211 - we have always billed 96372 (Admin) and J3420 (B1

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Orthocoderpgu

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Patient comes in just to have a B12 injection. In all the other offices where I have coded, we have always billed 96372 (Admin) and J3420 (B12). This covers the nurses services and the cost of the B12. However, I am now in a new office and the physician feels that on top of that we should be billing 99211 too. To me, that we be like charging the nurses services twice for the same service. Does anyone know where I can find coding rules to show that we should not be billing 99211 with 96372? With this doc, I'm going to need to prove this. Thanks for you help.
 
If you look in the CPT 2013 book under Appendix C, "Established Patient" the first example given for 99211 is "office visit for an 82 year old female, establised patient, for a monthly B12 injection with documented vitamin B12 deficiency." It would appear that your doctor is correct and you can bill the nursing visit and the administration of the injection.
 
The CCI edit shows that the codes can never be billed together and no modifier is allowed.

96372 99211 20090101 * 0

You are required to bill the code that describes the service provided, which in this case would be the 96372.
 
I believe the question is can both the 96372 AND the 99211 be billed together. The answer is no. The admin code of 96372 is bundled into the e/m code 99211. I'm getting a CCI edit on it.
 
I was always told that you bill with the fewest codes that describe the services performed.
Since 96372 is for the Admin, it seems that billing 99211 with it is billing twice for one service which would seem incorrect to me. Thanks for your input.
 
when the procedure is scheduled in advance of the encounter then the medical necessity for the procedure has already been determined, and the treatment already decided upon. This is the purpose of an E&M and it has already been charged.
The injection is the same as preplanned procedure.
All procedure contain the reimbursement necessary to the performance of the procedure, which includes an assessment of the patient at the time of the procedure ( VS, appearance of patient, notation of any distress), this assessment cannot be charged again using an E&M. i.e. no provider wil perform a procedure with a blindfold on and earplugs in.
This is why when you do bill an E&M with a minor office procedure you must show documentation of an assessment that is over above and beyond the assessment for the procedure. This is not possible with a scheduled injection performed by the nurse. The nurse can only follow a physician order, if anything is out of the ordinary, the physician is called in and the injection abandoned.
The CPT book has numerous examples in the appendix that are truely not relevant as they were developed many years ago and have not been brought up to date to be current with standards in todays world
There are some substances like B12 where specific diagnosis must be present to indicate medical necessity, if your patient does not have that diagnosis, then the drug nor the admin is paid, some try to circumvent this by using the 99211 which is paid, this cannot be allowed, therefore the rule of tumb is.. if a CPT code exists for the procedure performed by the nursing staff, then you must use the procedure code and not the 99211 regardless of the payment decision.
 
Can 96372 be billed for the administration by a nurse/MA if the doctor is not on-site or available if needed?
 
No you cannot have a physician office with only MA or RN on site and see patients for any reason. You have communicated to the state authorities that you are a physician office whic has very strict rules that must be followed one of those being that a credentialed provider must be on site. When you bill for services you must use an NPI for a rendering/supervising provider. If the provider is not on site he can be neither supervising nor rendering.
 
With exception we can code Both together

:)To repot 96372 with 99211, injection given without direct physician or other qualified healthcare professional supervision.append modifier 25 with injection code.

Refer: CPT-2013, CPT code -96372.
 
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:)To repot 96372 with 99211, injection given without direct physician or other qualified healthcare professional supervision. append modifier 25 with injection code.
Refer: CPT-2013, CPT code -96372.
 
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You cannot append a 25 modifier to the 99211 and bill the injection also. The 25 indicates that the E&M is significant and separately identifiable, if the patient comes to the office for an injection there is no activity performed by MA or RN that can be considered significant or separately is=dentifiable. If the physician sees the patient and performs an E&M that is significant and separately identifiable then there will be more than a 99211 to report. I am not sure where you are seeing this written in the CPT book in 2013, as it is not in mine anywhere. Also CMS has several communications written that states a 99211 cannot be billed for injections. A nurse or MA cannot provide an E&M that is significant since they cannot provide primary care, they only follow providers orders from previous encounters. Also in a physician office setting as I pointed out you cannot have a nurse or MA provide services without the provider being onsite. The nurse in the facility can do this and does all the time. Therefore perhaps what you are reading is intended for the facility use and not physician office.
 
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It would seem you cannot code the 99211 and the 96372 together, not with any modifier, being as the 96372 is covering the services.

BUT...my doctor asked me today...supposing the following two scenarios:

Scenario A:
Patient comes in for a B-12 injection - and the nurse also checks vitals, and administers injection.
CAN a 99211 be billed, and then append a 59 Modifier to the 96372?
If so, what ICD code(s) would apply to the 99211...just a V70.0?

The point being...in this specific case, the checking of vitals is NOT related to the B-12 injection.

From what I can make out...You would NOT append the 25 modifier to the 99211...you would bill that...and the 96372-59. Would the J3420 also be appended with the 59 Modifier in this case?

It's a rare circumstance, and I'm a little unsure if the use of the 59 Modifier is appropriate in this case.


Scenario B:
This one I am much clearer about, and was able to give a more definitive answer...
Assume the doctor sees the patient for a routine office visit, say a 99213 - and also gets a B-12 injection on the same day, and the nurse administers the B-12?

In this case, it seems to me fairly certain that the 59 Modifier appended to the 96372 is totally correct. But would you also append the 59 Modifier to the J3420 (I am guessing that you would)

Opinions?
Am I correct, as I think I am...about Scenario B?
And what about Scenario A (in the case of Scenario A, the patient did NOT see the physician at all, and so anything above 99211 would be ruled out as a valid coding - but there was a separate check of the vitals, not at all related to the B-12 injection)
 
Checking vitals is not separate from the injection and you cannot bill a 99211 just because your nurse checked the vitals prior to an injection. A nurse will always check the vitals prior to any injection as this information is integral to the administration of the injection. If the patient sees the patient and determines that an injection is necessary then you can bill the office visit with a 25 modifier you do not use a 59 on the injection.
 
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