Ob-Gyn Coding Alert

Meet these 3 criteria, and your claims will have no problem.

If your ob-gyn waives charging for simple patient visits with a nurse, your ob-gyn could be costing your practice deserved reimbursement.

All you have to do is follow these simple criteria for reporting 99211:

• the practitioner has the necessary training to perform the service;
• you can prove medical necessity; and
• the patient is established.

Heads up: Although you probably refer to this code as the -nurse’s code,- your ob-gyn and other personnel should report it if an E/M visit doesn’t meet the documentation requirements of the higher-level established patient E/M codes (99212-99215).

Our coding experts recommend that you 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 or other qualified health care professional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) if the service meets these three principles:

1. Staff Performs an Actual E/M Visit

To report 99211, a practitioner must perform an E/M service. In other words, don’t use 99211 simply to get any simple service paid.

Example: A nurse speaks to a patient on the phone and agrees to obtain a prescription refill for her. She comes to the practice an hour later, and the nurse hands her the prescription through the reception window.

Solution: Because the nurse did not evaluate the patient and no medical necessity required that she meet with her, you should not report an office visit. If the nurse couldn’t renew the patient’s prescription without evaluating her, however, she should have documented the medical necessity to support billing 99211.

Anytime you report 99211, the nurse should document the reason for the visit, a brief history of the patient’s illness, any exam processes such as weight or temperature, and a brief assessment.

What to look for: Check the documentation for notes such as “Wound has healed well,” “Blood pressure is normal,” or “Condition controlled with medication” to serve as proof that the practitioner met with the patient.

Also, make sure you have the date of service, the reason for the visit, proof that the nurse performed the service per the physician’s order, and the nurse’s signature.

Did you know? Any qualified personnel who are employees of the ob-gyn can report 99211, including medical assistants, licensed practical nurses, technicians, and other aides working under the physician’s direct supervision. But remember, these staff must be allowed to perform the evaluation service based on their State’s scope of practice or licensing regulations.

2. The Service Is Medically Necessary

If you think all nurse visits warrant using 99211, you could land in compliance hot water.

Example: A patient comes into the office for a blood pressure (BP) check because she recently had a high BP reading. Today’s reading is normal. 

Solution: You should report 99211 for this service.

Good advice: You should certainly use this code when it’s appropriate over waiving the charge, which some coders have seen happen before. Regardless of why the patient is in the office, she’s here to use your expertise and services, and that’s a legitimate charge you should bill. Sometimes the reimbursement is little more than the copay, but that’s not the point. We need to charge for our time, every time.

Example: On the other hand, suppose a patient phones your office and reports that she misplaced the dressing material the doctor had provided. She also reports that all of her BP readings at home for the last week were normal. She returns to your office with her readings. The nurse hands her new dressings, takes the readings, and puts them into the patient’s record.

Solution: Because the nurse simply hands her the new material and accepts the readings, you should not report 99211.

3. The Patient Is an Established Patient

The new patient E/M codes do not offer an equivalent to 99211. Registered nurses cannot report 99201, the lowest-level new patient office visit code, because physicians must see new patients, or established patients who have new problems, before you can report 99211.

Part of the specifications for using 99211 is that there is an established treatment plan and medical necessity for the follow-up, and it’s documented in the patient’s medical record. After all, you don’t have a nurse-level CPT^® code for new patients.

Take This 99211 Challenge

Think you’ve learned how to use 99211? Check out four common ob-gyn scenarios and determine whether you should report this code under these circumstances:

Scenario 1: A patient drops off a urine specimen.

What to do: You shouldn’t charge 99211 for a urine specimen drop-off because the nurse doesn’t perform an E/M service. For the specimen handling and conveyance, however, you may be able to report 99000 (Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory) if the practice incurs a cost in getting the specimen to the lab.

Scenario 2: A patient presents for a blood draw.

What to do: If the patient comes in only for a blood draw, you should charge 36415 (Collection of venous blood by venipuncture) instead of 99211. But you may report 99211 if the nurse takes the patient’s history or documents a chief complaint. Some carriers, however, may bundle the E/M service with the venipuncture code or vice versa.

Scenario 3: A patient picks up a birth-control refill and tells the receptionist that the medication causes some unpleasant side effects. The nurse documents the problem and checks with the ob-gyn regarding changing the patient’s dose.

What to do: Because the service involves the nurse and a problem, you can report 99211.

Scenario 4: A nurse administers a Lupron injection.

What to do: Usually, the administration code (96372, Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) covers the nurse’s work, so you shouldn’t submit 99211 as well. These services are included in the procedure charge.