Oncology & Hematology Coding Alert

You could save $20 per encounter.

You cannot blindly turn to code 99211 whenever an established patient is evaluated by nurses and other non-physician healthcare professionals. You are very likely to face a denial if you do so. Here is how you can ensure proper reimbursement for 99211 every time you report this code.

Check the Code Criteria

The first key criterion for reporting 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 problems[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) is that you should use this code for an established patient.

Follow this: One of your physicians, or more than one physician, in the same specialty and under the same group ID as the provider performing the service, must have seen the patient for a face-to-face service within the past 36 months.

In general, the visits you can report using 99211 are usually for minor problems where vitals may be checked, injections are given, or current medications are reviewed and a decision of some type is made based on a previous directive or order from the treating provider (physician or nonphysician advanced practitioner). You may frequently encounter such visits in your oncology practice. The visit is typically brief of five minutes or less.

Red flag: If a nurse sees a patient prior to the patient seeing her physician, this is part of the E/M service being provided by the physician. Do not separately bill for this service.

Unlike other established patient outpatient E/M codes, you don’t actually need to reach a particular level of history, exam, or medical decision making to report 99211. This is because the code descriptor does not reference the level of those key components.

Don’t overlook: If you want to make sure that your practice is reimbursed for the visit, the patient must be established, the service must be medically necessary, and a well-documented E/M provided. To ensure the documentation supports billing 99211, your provider should include at least these five criteria:

• The date of the visit.
• The name of the service provider.
• Reason for the visit.
• Some indication of patient evaluation (e.g. interval history and/or brief exam, including vital signs such as weight and temperature).
• Brief assessment of the situation reflecting some management of the patient based on a previous order and protocol standard of care.

Profit: If you provide enough information, you could receive approximately $20 per 99211 encounter (0.56 total non-facility RVUs times the 2014 national, geographically unadjusted Medicare conversion factor of $35.8228). If your practice performs even five of these visits a week, annually, the practice would receive or lose over $5,000.

Avoid Using 99211 in Some Circumstances

According to experts, there are at least three “don’ts” when it comes to reporting 99211 to Medicare:

1. Don’t use 99211 for a nurse visit for services that are a part of another E/M.

Example: A nurse measures the patient’s height, weight, and blood pressure before the physician sees the patient. The nurse’s work would be a part of the physician’s E/M.

2. Don’t report 99211 for telephone calls to patients because there has to be a face-to-face contact.

Example: A nurse returns a patient’s phone call and gives instructions over the phone.

3. Don’t underestimate the impact the documentation can have on your reimbursement. When it comes to documenting 99211 visits, the progress note is critical. The care provider must provide the reason and the details for the encounter. This could include educational services or an evaluation of the patient’s condition with management of the care plan initiated by the physician.

Example: Problems can occur when billing 99211 with a “routine BP check” In addition to the BP reading, the medical record must also state why the patient came in for a BP check and the decision made based on the data (BP) collected.

To clearly state that there is a medical necessity for performing 99211, the physician may document “patient BP not under control. BP meds increased to 300 mg. Patient is to return in three weeks for a BP check. If BP is still not under control, we will change his BP meds.” rather than the physician documentation just stating “return in 6 weeks for BP check.” That only justifies a BP check and not an E/M.

4. Don’t use 99211 to report another service that has its own CPT^® code.

Example: If a patient is seen solely to receive an influenza vaccination, which the nurse provides, the practice should report the code for vaccine administration (plus the code for the flu vaccine itself) rather than 99211.

5. “Do not report a 99211 visit when chemo or other infusion therapy is administered on the date of service for Medicare patients,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Director of Reimbursement and Advisory Services, Altegra Health, Inc. The assessment the nurse performs includes the value of 99211 when reporting the administration CPT^® codes.  [Federal Register, Jan 7, 04 Vol. 69, No. 4 (1093-1094) and Medicare Claims Processing Manual Chapter 12, Section 30].

6. Don’t report 99211 to Medicare for a “nurse visit” under the physician’s Medicare provider number unless the encounter fulfills Medicare’s “incident to” requirements. Medicare Claims Processing Manual Chapter 12, Section 30.6.4, 60.6.5, Medicare Benefit Policy Manual, Chapter 15, Sections 50 and 60]