Pediatric Coding: Are You Allowed ‘calming Shot’ Fee?

.tags Situation: A patient of ours was going to have an MRI at the hospital. His mother stopped by at 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 and the patient did not see the doctor. Can we bill the injection in addition to an Evaluation/Management service? What diagnosis would apply here?

Answer: If the nurse provided an E/M of the patient in addition to administering the Diazepam injection, then start by coding an appropriate E/M service. In this situation, the most likely E/M code is 99211 since the patient didn’t see the physician.

Use modifier 25 (Significant, separately identifiable E/M service by the same doctor 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.

Then, report the injection code (such as 96372, Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]: subcutaneous or intramuscular). Lastly, use 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: As the doctor did not see the patient, verify that he was in the building at the time and wrote an order for the injection. This will help support a billable service according to incident-to rules, where applicable.

The nurse should complete an E/M note to support billing 99211. This should include a history and assessment, including important signs. That apart, you should in conjunction with the physician document the decision to proceed with the requested injection. The doctor should countersign this note.

For more tips to wiggle out of tough evaluation & management coding situations such as this and reduce denials, sign up for a medical coding guide like Supercoder.

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