Minimal E/M Exam Must Be Documented to Bill 99211
Published on Sat Apr 01, 2000
Even though 99211, the level one code for an established patient, does not require documentation of the usual evaluation and management (E/M) categories, some written record is required to bill correctly for this service. This means that if a patient comes in and a nurse, nurse allergist or audiologist performs even a minimal level of evaluation and management, the service can be billed. But if only a service that has its own code is performed, CPT 99211 should not be coded or charged.
According to the CPT definition, 99211 is used for an 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.
When physicians personally see an established patient, the level of the visit is unlikely to be billed any lower than 99212 (level two office visit that requires a problem-focused history and examination, and straightforward medical decision-making). The level one established patient code, 99211, is reserved for short visits during which the patient is seen by someone else. In the case of otolaryngologists, this typically would be a nurse (for injections and wound checks), a nurse allergist or an audiologist (for audiology testing).
Still Need Documentation
CPTs 99211 is the only code in the office or other outpatient setting category with no documentation guidelines. History, examination and medical decision-making are not required. Instead, minimal documentation to indicate that E/M actually was performed is enough to support a 99211 claim.
But that does not mean the documentation can be overlooked. Although some otolaryngologists use 99211 whenever a patient sees a nurse, such billing is incorrect, says Cynthia Swanson, RN, CCS-P, a coding and reim-bursement specialist with Seim, Johnson, Sestak & Quist, LLP, an accounting and consulting firm in Omaha, Neb. They need to document enough to indicate a visit actually took place, Swanson says, noting that this could include taking the patients vital signs or answering questions.
For example, an established patient comes in complaining of dizziness and sees the audiologist, who performs audiometric testing (92557, comprehensive audiometry threshold evaluation and speech recognition [92553 and 92556 combined]; 92567, tympanometry [impedance testing]; 92568, acoustic reflex testing).
If that is all the audiologist does, a visit cannot be charged, says Ann Hughes, a coding specialist with Mid-Vermont ENT in Rutland, Vt. Instead, the service actually rendered (i.e., the audiometry tests) should be billed using the codes listed above.
If the visit involves more than just these procedures (i.e., the audiologist does a dizzy patient workup, in which the audiologist tries to pinpoint the exact history of occurrences or has the patient [...]
