EM Coding Alert

Reader Questions:

Understand ‘QHP’ Acronym to Code These Encounters

Published on Wed Sep 21, 2022

Question: Should I be reporting all services performed by a nurse, including those provided to new patients, with 99211?

Ohio Subscriber

Answer: While 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional) does not require history, exam, medical decision making (MDM) or the presence of a physician, automatically reporting services provided by a nurse with 99211 is not correct and could result in audits and revenue loss for your practice.

First, take a look at the code descriptor itself, which says 99211 is for an established patient, not a new patient. New patients must be reported with a code such as 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making …), at a minimum. Also, new patient encounters typically require the expertise of a physician or other eligible qualified healthcare professional (QHP) since neither the patient nor their condition(s) are known to those in the practice. Reimbursement is typically higher for a new patient visit at the same level (e.g., 99202 versus 99212) because of the extra work and time involved to gather all the information and diagnose any new conditions.

Also, remember that Medicare regards certain services provided by someone other than a physician or QHP as incident to the physician or QHP, which you cannot report for a new patient. One of the many requirements for incident-to reporting is that there must be a previously established course of treatment in place, which of course wouldn’t be the case for a new patient.