Part B Insider (Multispecialty) Coding Alert

Published on Fri Jul 16, 2004 PDF

If a visit warrants CPT 99211 , you can recoup an additional $20 or more

Although 99211 is often called the "nurse's code," physicians and other personnel should report 99211 if an E/M visit doesn't meet the documentation requirements of the higher-level E/M codes (99212-99215).

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. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) if the service meets three criteria:

1) Staff Performs an Actual E/M Visit. To report 99211, a provider must perform an evaluation and management service. Don't use 99211 to get any simple service paid, says Quinten Buechner, president of ProActive Consultants in Cumberland, WI.

Suppose a nurse speaks to a patient on the phone and agrees to write him a prescription refill. He comes to the practice an hour later, and she hands him the prescription through the reception window.

Because the nurse did not evaluate the patient and no medical necessity required that she meet with him, she should not report an office visit.

But if the nurse couldn't renew the patient's prescription without evaluating him, she should have documented the medical necessity to support billing 99211. If the nurse had done this, you can report 99211 and recoup an additional $20 or more for the visit.

"I advise physicians that for nurse visits, 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," says Jay Neal, an independent coding consultant in Atlanta.

Look 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.

Any qualified personnel who are employees of the physician can report 99211, including medical assistants, licensed practical nurses, technicians and other aides working under the physician's direct supervision.

2) The Service Is Medically Necessary. Suppose the surgeon sees an elderly postoperative patient with a minor infection. The surgeon shows the patient how to apply antibiotic to the wound and change the dressing. The following day, the patient tries to change the bandages but cannot. She returns to the office, and the nurse reapplies the dressing for the patient. The nurse should report 99211 for this service.

Not all nurse visits will warrant reporting 99211, however. Suppose the patient phones your office asking for more antibiotic cream. She returns to your office and the nurse hands her a new tube of medication. In this case, there is no E/M service and 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.