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 of a new patient, which requires these three key components: a problem- focused history; a problem-focused examination; and straightforward medical decision-making) or any other new patient service.

Don't forget: A nurse can only tend to established patients. If the visit is the patient's first time at your practice, a doctor's presence is required for all office or other outpatient services.

When Should You Use 99211?

Formulating appropriate uses of 99211 by nurses is an ongoing challenge for coders and pediatricians alike.

"Everybody says they need to be using more 99211s, but when you try to figure out what you can use them for, the categories are kind of narrow," Rappo says.

"Blood pressure recheck, burn/wound dressing and weight check are obvious" opportunities to report 99211, Rappo says. You might also report 99211 for reading the results of a PPD (purified protein derivative) test for tuberculosis, " because the nurse has to actually look at the structure and the reaction, and document that in the record," he says.

Suture removal, throat cultures and allergy-shot administration are other examples of situations when using 99211 is recommended. But from there, experts say, 99211 options are less lucid.

Watch Out If Reporting 99211 and Separate Service

Confusion over what constitutes a 99211 visit is apparent in how most carriers handle claims in which a nurse provides 99211-level service and a separate service in the same visit.

Take the example of a child reporting for a vaccination. Logic would dictate reporting 99211 in addition to the vaccination code (90471 for one vaccine, 90472 for each additional vaccine), says Jeffrey Linzer Sr., MD, FAAP, assistant professor of pediatrics at Emory University. However, insurance carriers usually don't see it that way.

"When a nurse gives a vaccination, there is a policy in most offices about what giving the vaccination entails," Linzer says. "Usually, the nurse is going to ask if the child has any acute illnesses at that time, because there are  certain indicators that tell you when giving the shot would endanger the patient. With vaccinations, it's not that common for someone to just come in for a shot without some other service provided."

Red flag: That "other service," experts say, usually amounts to a 99211 visit, but most carriers disagree with that logic and only reimburse for the injection.

"The nurse is going to do some preventive counseling with a vaccination, so it makes perfect sense to try to use it for a vaccine visit," Rappo says. "But most insurers will just deny it out of hand, saying it's a service that's covered by the vaccine code itself."