Internal Medicine Coding Alert

Published on Fri Jan 25, 2008 PDF

Question: An established patient with a plan of care in place for hypertension reports to the internist. A qualified nonphysician practitioner (NPP) performs a blood pressure check. The patient's file indicates that the internist started the patient

on a new medication during an E/M visit two weeks ago, and the internist scheduled this visit specifically to check the patient's BP. Can we report 99211 in this instance?

Michigan Subscriber

Answer: Yes, you can 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) for the service. When reporting 99211 for BP checks, you must be sure that the internist orders the test for a clinical reason -- such as possible patient side effects from a new

medication regimen.Check out this guidance from TrailBlazer, which lays out its requirements for billing 99211.

"Code 99211 services must be reasonable and nec-essary for the diagnosis or treatment of an illness or injury. ... CPT code 99211 describes a service that is a face-to-face encounter with a patient consisting of elements of both evaluation

and management. The evaluation portion is substantiated when the record includes documentation of a clinically relevant and necessary exchange of information (historical information and/or physical data) between the provider and the patient."

"The management portion of code 99211 is substantiated when the record demonstrates influence by the service of patient care (medical decision making, provision of patient education, etc.)," TrailBlazer reports.

Alert: TrailBlazer instructs providers to include the following documentation to ensure 99211 claim clarity:

• Record of patient's blood pressure and other vital signs

• Record of clinical reason for checking blood pressure (for instance: follow up to previous abnormal finding, symptoms suggestive of abnormal blood pressure, etc.)

• List of patient's current medications (with notation of level of compliance)

• Proof of the physician's evaluation of the clinical information obtained and his management recommendation for the patient.