Primary Care Coding Alert

Proper use of low-level office visit codes (99201 and 99211) can provide an important stream of revenue for family practices, according to Debra Wiggs, CMPE, chief executive officer of Community Physicians Administrative Support Services, LCC (ComPASS), a billing and collections firm that provides support to 45 primary care practices in Washington state. However, many practices misuse these codes and may incur penalties.

99211 Reported More Frequently

Established patient code 99211 is assigned more frequently than the corresponding new patient CPT 99201 and is often referred to as a nurse visit. This is a basic level of service that doesnt require the presence of a physician or nonphysician practitioner [NPP], Wiggs explains. Care is usually provided by a registered nurse, licensed practical nurse or certified medical assistant. It may be assigned when:

diabetic patient comes in for a glucose check,
patient comes in to have sutures removed,
newborn is brought in for a weight check,
child is brought in for peak-flow meter instruction, or
postsurgical patient needs his or her dressings changed.

Unlike other office visit E/M codes, 99211 has no documentation requirements for history, physical exam or medical decision-making, Wiggs points out. However, the nurse must be face-to-face with the patient, and must record the visit in the chart. These notes should include the date, the reason for the patients visit, the service provided per the doctors order and the nurses signature.

A typical visit might occur if an established patient comes in because of a minor sore throat. The nurse conducts a nursing assessment and performs a rapid strep test, which is negative. The patient then leaves without seeing a physician.

Virtually all 99211 visits are billed as incident to services under the physicians (or NPPs) name and provider identification number, and must follow the appropriate guidelines.

When 99211 is reported for a follow-up visit with a patient who has an existing condition, family practices must consider two specific requirements, Wiggs says. First, the physician or nonphysician practitioner must have originally established a treatment plan and dictated the medical necessity of having the patient follow-up with the nurse. Secondly, the nurse must be under the direct supervision of the physician or NPP. Although they do not need to be in the exam room, they must be physically present in the office or clinic. Availability by phone does not meet the requirement.

When Not to Report 99211

Excessive reporting of 99211 has been the cause of Medicare fraud investigations, and practices must ensure they are using the code correctly. It is easy to assign this code for services that are clearly not covered, Wiggs says. Examples include:

1) Telephone calls. Frequently, practices will talk to patients by phone to discuss [...]