Cardiology Coding Alert

Even though 99211, the level one code for an established patient does not require documentation of the usual evaluation and management (E/M) categories, some written record is required to bill correctly for this service. This means that if a patient comes in and a nurse performs even a minimal level of evaluation and management, the service can be billed. But if the nurse only performs a service that has its own code, such as venipuncture, 99211 should not be coded or charged.

According to the CPT definition, 99211 is used for an 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.

When physicians personally see an established patient, the level of the visit is unlikely to be billed any lower than 99212 (level two office visit that requires a problem-focused history and examination, and straightforward medical decision-making). The level one established patient code, 99211, is reserved for short visits during which the patient is seen by someone else, typically a registered or licensed practical nurse.

Still Need Documentation

CPTs 99211 is the only code in the office or other outpatient setting category with no documentation guidelines. History, examination or medical decision-making is not required. Instead, minimal documentation to indicate that E/M actually was performed is enough to support a 99211 claim.

But that does not mean the documentation can be overlooked. Although some cardiologists use 99211 whenever a patient sees a nurse, such billing is incorrect, says Cynthia Swanson, RN, CCS-P, a cardiology coding and reimbursement specialist with Seim, Johnson, Sestak & Quist, LLP, an accounting and consulting firm in Omaha, Neb. They need to document enough to indicate a visit actually took place, Swanson says, noting that this could include taking the patients vital signs, verifying his vital signs or answering questions.

If a coumadin patient comes in and all the nurse does is draw blood, a visit cannot be charged. Instead, the service actually rendered (i.e., drawing the coumadin) should be billed using the appropriate procedure code. For coumadin and other laboratory collection or draws, cardiologists should use code 36415 (routine venipuncture or finger/heel/ear stick for collection of specimen[s]) for third-party payers; for Medicare carriers, they should bill HCPCS code G0001 (routine venipuncture for collection of specimen[s]).

If the service requires both the nurse and the cardio-logist, as would be the case if coumadin levels need adjust-ment, the requirements for an E/M visit would be met if the adjustment is noted in the patients chart, Swanson says.

She notes that the draw itself is subject to Medicares incident to rules, which means the draw must be taken under the general supervision of the physician, who need not be in the same room.

When labs are drawn, whether 99211 can be billed depends on what else took place. If the intent is just to draw the labs, you shouldnt bill for the E/M service, Swanson says.

Pre-scheduled injections are coded similarly. If only the injection is performed, cardiologists should bill only 90782 (therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) and the HCPCS J-code for the drug injected.

Blood pressure testing is different, Swanson says, because there is no CPT code to describe the service. When a nurse performs this service, it may be billed as long as it isnt bundled into another service the cardiologist is performing and documentation of the visit is provided.

Even here, however, some discretion is still required, says Susan Callaway-Stradley, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. If someone walks into your practice and asks to have their blood pressure taken, that is just a courtesy and shouldnt be billed, Callaway-Stradley says. But if a patient has been given medication for blood pressure and returns a few days later to determine the efficacy of the dosage, at that point youre providing an E/M service.

If the patients blood pressure were abnormal, the cardiologist would get involved and the level of the E/M visit then would increase, she adds.