Eli's Rehab Report

Published on Wed Feb 25, 2004 PDF

Learn 99211's requirements to determine whether your visits warrant it

Because PM&R practices often delegate simple patient visits to a nurse, you might think you're familiar with all of 99211's nuances. But you shouldn't report CPT 99211 until you're sure the visit meets certain criteria.

You can report 99211 with confidence as long as you apply the code only when the practitioner provides a medically necessary service to an established patient. And remember, although this code is often referred to as the "nurse's code," your physiatrist and other personnel should report it if an E/M visit doesn't meet the documentation requirements of the higher-level codes (99212-99215, Office or other outpatient visit ...).

Coding experts recommend that you report 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problems are minimal. Typically, 5 minutes are spent performing or supervising these services) if the service meets the following three criteria:

1. Staff Performs an Actual E/M Visit

To report 99211, a practitioner must perform an evaluation and management service, so don't use 99211 simply to get any simple service paid, says Quinten A. Buechner, MS, MDiv, CPC, CHCO, president of ProActive Consultants LLC in Cumberland, Wis.

Suppose a nurse speaks to a patient on the phone and agrees to write him a prescription refill. He comes to the practice an hour later, and she hands him the prescription through the reception window. Because the nurse did not evaluate the patient and no medical necessity required that she meet with him, she should not report an office visit.

If the nurse couldn't renew the patient's prescription without evaluating him, however, she should have documented the medical necessity to support billing 99211. "I advise physicians that for nurse visits, the nurse should document the reason for the visit, a brief history of the patient's illness, any exam processes such as weight or temperature, and a brief assessment," says Jay Neal, an independent coding consultant in Atlanta.

Look for notes such as "Wound has healed well," "Blood pressure is normal," or "Condition controlled with medication" to serve as proof that the practitioner met with the patient.

Any qualified personnel who are employees of the physician can report 99211, including medical assistants, licensed practical nurses, technicians, and other aides working under the physician's direct supervision.

2. The Service Is Medically Necessary

Suppose your physiatrist sees a stroke rehab patient and records a higher-than-normal blood pressure (BP) reading. She reports that she had an argument with her son on the way to your office, which caused the high blood pressure. The physiatrist asks her to return the following day for another BP check.

When the patient presents the next day, the physiatrist checks her blood pressure, which is normal, and records it in her chart. Because the patient had a history of stroke and the physiatrist believed it was medically necessary to confirm whether her blood pressure was high, the physician should report 99211 for the BP check. 

BP checks won't always be necessary, however. Suppose a patient brings his elderly mother to your practice so the physiatrist can evaluate her multiple sclerosis. While in the waiting room, he asks the nurse to check his blood pressure because he wonders whether it is high. The nurse performs the BP check, but you shouldn't report 99211. "No medical reason exists for performing the service," Buechner says.
 
3. The Patient Is an Established Patient

The new patient E/M codes do not offer an equivalent to 99211. Registered nurses cannot report 99201, the lowest-level new patient office visit code, because physicians must see new patients or established patients who have new problems, before you can report 99211.