General Surgery Coding Alert

Do patients come into the office for blood pressure checks or other brief E/M services on days they don't see the surgeon? If so, your general surgery practice can bill Medicare and some private insurers for many of these "nurse-only" visits (99211) if your nursing and nonphysician practitioner (NPP) staff know how to provide and document the services.

Remember, report 99211 (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) only when established patients receive services from nursing staff and NPPs, including such personnel as physician assistants (PA), nurse practitioners, and certified nurse specialists (CNS), as part of a physician's plan of care for a health problem.

Although physicians can bill 99211, typically the lowest level E/M code a physician will report for an established patient is 99212 because it requires at least two of the three E/M components (history, exam and medical decision-making). Code 99211 services may be an integral part of a patient's care plan but "incident-to" the physician's care, according to Mary Mulholland, CPC, RN, reimbursement analyst at the University of Pennsylvania's department of medicine in Philadelphia. To bill Medicare for 99211, there must be a medical necessity for providing the E/M service and the physician must be present in the office suite in case the patient needs to be seen. Private insurers may not have that requirement, however. Diagnosis Must Accompany Routine Blood Pressure Checks You can bill 99211 for blood pressure monitoring for hypertensive patients under a surgeon's plan of care, but only if there is established medical necessity for the blood pressure check, says Catherine Brink, CMM, CPC, president of Health Care Resource Management Inc., in Spring Lake, N.J.

"If a patient comes in to have her blood pressure checked by the nurse because the physician documented that she should have it monitored every two weeks, the visit can't be billed," Brink says. Providing a blood pressure check in the absence of other problems should be considered "a good-will gesture" and does not constitute medical necessity for billing, she says. If there is medical necessity for blood pressure monitoring, however, it will meet the criteria for 99211, Brink says. For example, the surgeon examines a 65-year-old female patient during a preoperative exam and finds that her blood pressure is high. He decides to put her on medication to correct the problem. He notes in the chart that "the patient should return in two weeks to see the nurse for a blood pressure check, an evaluation of how the new BP medicine is working, and [...]