Per CPT there is no requirement for History, Exam or MDM for a 99211 visit. All you really need to document is the chief complaint. Per CPT, "the presenting problem is minimal" and this service "may not require the presence of a physician."
BUT ... all procedures include a basic E/M in the RVU for the procedure. If you are giving an injection, or drawing labs you are already being paid for that basic evaluation of the patient that is necessary for that procedure. So you should NOT be coding 99211 or any other E/M service, UNLESS you have a significant, separately identifiable E/M
Example: Patient comes in for joint injection. Also mentions/complains of cough and rhinnorhea. The evaluation and management of the cough & rhinnorhea is a significant separately identifiable E/M from the basic evaluation that would be done before/after giving the injection. You would code that E/M and append a -25 modifier.
Example: Patient comes in for joint injection. Nurse takes vitals and checks previous injection site for any signs of infection or reaction. This is NOT a significant, separately identifiable E/M from the procedure. Payment for this basic evaluation is already included in the payment for the procedure. NO E/M service should be coded.
Hope that helps.
F Tessa Bartels, CPC, CEMC