Part B Insider (Multispecialty) Coding Alert

Published on Fri Mar 02, 2012 PDF

Hint: Don't use level 1 visit for all vaccinations and allergy shots.

Many physician coders are confused about when to use CPT code 99211, because they tend not to use 99211 when they should, or they'll use it incorrectly. Study these quick strategies to improve your reimbursements.

Strategy 1: Don't limit 99211 use to nurse visits only.

Fact: Physicians, nurse practitioners, and physician assistants can use 99211 as well as nurses. If a non-physician bills under the billing physician's name using 99211, you still have to make sure you follow the "incident-to" regulations. Ensure that your documentation actually supports the use of 99211.

Strategy 2: Don't automatically use 99211 to bill for allergy shots and vaccinations if the provider did not provide any other service.

Fact: You can't bill 99211 for just an allergy shot or vaccination. For allergy shots, you should code 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) for a single shot or 95117 (...2 or more injections) for two or more shots.

If the billing provider supplies the allergy serum, then you should bill for the serum at the time the provider makes the new serum. For vaccinations, bill the vaccine separately and use 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]) for a single injection, 90473 (Immunization administration by intranasal or oral route; 1 vaccine [single or combination vaccine/toxoid]) for a single nasal/oral vaccination, or +90472 for each additional vaccination.

Note: If the nurse provides a separate, medically necessary E/M service -- for example, if the patient has a separate illness or a reaction to the injection that requires a separate evaluation -- then you can separately bill for these services using 99211. Make sure the documentation supports these services.

Strategy 3: "Incident-to" rules apply to 99211 when non-physicians perform these services.

Fact: You should follow the incident-to rules in order for a physician to bill for the services of a nurse.

The person performing the service must be an employee or contractor of the billing physician or group under which you're billing the service. Also, the service must be in the physician's office, and the physician must be "in the suite" during the service. The physician must have prescribed the service, and the patient must be an established patient.

Strategy 4: Don't buy into the myth that nurses can bill for all levels of evaluation and management (E/M) visits as long as the physician is "in the suite."

Fact: Physicians can only bill for the services of nurses using 99211 under the incident-to regulations. Under incident to, physicians can bill for the services of nurse practitioners, clinical nurse specialists, and physician assistants for all levels of E/M services.

Strategy 5: CPT and Medicare may differ on when 99211 Is appropriate.

Even if CPT advises reporting 99211 in certain circumstances, you should always defer to payer guidelines when billing.

For instance: In CPT, a note under 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) says that in absence of direct physician supervision, you should report 99211 instead. But to bill incident-to, 99211 requires direct physician supervision under Medicare guidelines.

Fact: For Medicare (and those payers with the same rules), you won't be able to charge 99211 or 96372 for injections performed by nurses without direct supervision. You'll have to accept this as a non-covered service.

Support: Medicare Claims Processing Manual, section 30.5.C, states that CPT's guideline to report 99211 for injections without direct supervision "does not apply to Medicare patients." Although the CMS manual references CPT 2006 and the injection code in effect at that time (90772), you should heed the instruction that, "If the RN, LPN or other auxiliary personnel furnishes the injection in the office and the physician is not present in the office to meet the supervision requirement, which is one of the requirements for coverage of an incident to service, then the injection is not covered. The physician would also not report 99211 as this would not be covered as an incident to service."

You can access CMS's online manuals at www.cms.gov/Manuals/IOM/list.asp.