Part B Insider (Multispecialty) Coding Alert

Published on Tue Jul 27, 2004 PDF

But make sure to justify medical necessity

Many physicians'offices have set up "anticoagulation clinics" to manage patients on Warfarin Sodium (Coumadin) in recent years, say experts. In these clinics, patients come in for tests such as prothrom-bin time (PT) or international normalized ratio (INR). It's common for the patients undergoing these tests to see a nurse face-to-face for additional evaluation or checks of vital signs. Some clinics can see ten patients in one session and schedule two sessions per week.

But increasingly physician offices are facing controversy over whether to bill a level one evaluation and management visit (CPT 99211 ) for the nurse's encounter with the Coumadin patient. "99211 is the one code that's always fraught with difficulty," says Bruce Rappoport with RCH Healthcare Advisors in Fort Lauderdale, FL.

If the patient is just coming in for a blood draw and then obtaining the results later by phone, there's not enough evaluation to justify billing 99211, adds Rappoport.

In general, with 99211 claims, there must be a medical necessity for a nurse visit, says Catherine Brink, president of HealthCare Resource Management in Spring Lake, NJ. "If she's just giving the injection and not interacting with the patient, there's no medical necessity for a 99211."

Even if the nurse is interacting with the patient face-to-face, there should be some actual reason for that interaction, notes Rappoport. "If there was a necessity that the patient had to have some sort of evaluation either relevant to the Coumadin therapy or hypertension that was not well controlled," that would make sense, adds Rappoport. For example, the nurse shouldn't necessarily be checking blood pressure unless there's some question as to whether the patient needs a change in blood pressure medication.

One reason for a face-to-face encounter would be if there are specific questions about how the patient is doing on medication, says Brink.

If the physician has just changed the patient's medication and wants the nurse to follow up with the patient, that would justify billing a 99211, adds Rappoport.