Pediatric Coding Alert

Knowing when to report CPT 99211 can confound the most experienced pediatric practices but asking three key questions should solve the 99211 puzzle. Code 99211 continues to be a source of confusion and debate for many coders as evidenced by frequent reader questions, such as "Requirements of 99211," Pediatric Coding Alert, August 2002. Remember that 99211 usually triggers a copayment, and families should be made aware of this. In addition, the code is for established patients only 99211 (Established patient office visit usually the presenting problems are minimal). 1. Did Auxiliary Personnel Perform the Service? "99211 is often called a nurse visit," says Catherine Brink, CMM, CPC, president of Health Care Resource Management Inc., in Spring Lake, N.J. It is the lowest-level E/M visit for an established patient and is typically used when the nurse sees a patient for a minor problem. Although physicians and nonphysician practitioners, such as nurse practitioners and physician assistants, are not barred from using 99211, they will use a higher-level E/M code in most cases because of the greater complexity of care they usually provide.

Many coders don't realize that 99211 can be used by office employees other than the nurse, says Kathy Pride, CPC, CCS-P, HIM applications specialist with the San Rafael, Calif.-based QuadraMed. Any qualified "auxiliary personnel" who are employees of the physician, such as medical assistants, licensed practical nurses, technicians and other aides, and are working under the physician's direct supervision can provide services to patients under the "incident-to" umbrella using 99211, as long as the visit meets the "medical-necessity" requirement for billing an E/M code, she says. The physician must be present in the office when the service is performed, and the auxiliary personnel must be qualified to perform the service. Note: For more on auxiliary personnel, read Section 2050.1 of the Medicare Carriers Manual. 2. Does a Code Describe the Service? Coders frequently question whether they can use 99211 when a patient comes to the office for common procedures, such as lab work. The first question the coder should ask is: Does the service that was provided have its own CPT code?

"If the service has an identifiable code, you bill that code," Pride says. Routine Lab Checks Aren't Covered For example, a patient comes to the office for a urinalysis as part of routine lab work scheduled a week before a regular checkup. Use CPT code 81002 (Urinalysis, by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy).

You cannot code 99211 for the time that the nurse or assistant spends with the patient unless another medically necessary service is provided in addition to the [...]