Pediatric Coding Alert

Offices forfeit pay if nurses don't perform most level-one established patient E/M services

If an established patient reports to your office and is seen only by a nurse who performs a basic evaluation and management service, experts recommend using CPT 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) to ensure maximum reimbursement and increase office efficiency.

Typically, practices use 99211 to report services provided solely by a nurse - so often, in fact, that 99211 is called the "nurse visit" code. You can report 99211 when a pediatrician sees the patient, but the E/M visit would have to be extremely cursory.

According to CPT 2004, offices should report 99211 when the presenting problem(s) are minimal and the provider spends about five minutes performing or supervising these services.

Pediatricians rarely take time to perform these services (e.g., weight checks, blood pressure rechecks, burn dressing, etc.), meaning that nurses are the sole caregivers in almost all 99211 visits. Free Up Your Pediatricians With 99211 If nurses handle most 99211 visits, it allows pediatricians in your practice to devote more time to higher-level (and higher-paying) services.

"If you look at the documentation requirement for 99211, it's sort of like a pediatrician didn't have to be there," says Peter Rappo, MD, FAAP, a practicing pediatrician and assistant clinical professor of pediatrics at Harvard University School of Medicine.

Payoff: When a pediatrician is needed during an office visit, the visit will almost always be at least a level-two (99212) service, Rappo says. From a financial standpoint, reporting 99211 when a physician sees the patient doesn't make much sense, because the relative value unit (RVU) for 99212 is much higher.

"If a physician wishes to use it (99211) when he sees a patient, he can. But why would he want to?" Rappo asks.

Consider this example: An established 12-year-old patient with attention deficit hyperactivity disorder (ADHD) reports to the office for a Ritalin refill prescription and to have his progress monitored. The nurse checks the patient's height and weight and notes his progress, with particular attention to appetite, sleeping patterns and school issues.

She then gives the patient a Ritalin prescription written by the pediatrician and sends him on his way. The entire encounter takes four minutes and 30 seconds.

Best bet: This is an ideal situation to report 99211, because the nurse monitored the patient's ADHD progress in addition to giving him the Ritalin refill prescription. On the claim, be absolutely sure you document the E/M services the nurse performed to justify using 99211.

Experts warn: Nurses cannot use the level-one E/M code for new patients (99201, Office or other outpatient visit for the evaluation and management [...]