Wiki 99211 - documentation requirements

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JenBrz

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Trying to figure out 99211. Here’s an example:

Patient comes to office with blood glucose logs. Their appt is scheduled with Nursing staff and a nurse reviews patient glucose logs and sees their numbers are too high. Nurse documents “as per Dr. X patient to increase insulin”. Nurse then signs off.

Is this still a 99211?
It seems like MDM was done due to the change in treatment plan, so wouldn’t this qualify as a 99212?
Doc DID NOT sign off on encounter but it says “as per Dr. X” is that acceptable for either 99211 or 99212?

Next, patient has appt with Nurse to review logs but cannot come to office and visit is conducted over the phone. Same as above, “as per Dr. X patient increase insulin”. Is a phone visit 99441 billable here? Doc does not sign encounter; only Nurse

Can someone please help with this? I am probably over thinking this whole thing but I cannot get an answer from anyone.

If you have an answer please explain
 
In your first example, unless the physician actually saw the patient, I would not bill anything higher than 99211. The physician would need to indicate this and sign the note. If the patient was actually seen by the physician, likely higher than 99212 as it seems there is a chronic problem not stable and prescription management. But I would not count the physician's work if he only discussed it with his nurse over the phone. 99211 may be performed by RN and documented as such. It's probably good medical practice to have the physician co-sign the RN note, but I don't believe it is REQUIRED.
In your second example, telephone (audio only) visit with nurse, 99441 is not the correct code. 99441-99443 are reserved for billable providers (MD, DO, PA, NP, CNM, etc.) 98966-98968 may be more appropriate for RN services depending on your state and the payor. The overseeing clinician goes on the claim. Please note "QUALIFIED health care professional" in the description. If your nurse is an LPN, and your state does not license LPN, then you definitely may not bill for the service.
98966 Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

Please note - there have been dozens of changes to the telehealth services. You may want to check with the carrier if 98966-98968 is even a covered service.
My personal 2 cents is if this was a one time thing, it's not worth the research required to even see if it is possibly billable.

 
csperoni said:
In your first example, unless the physician actually saw the patient, I would not bill anything higher than 99211. The physician would need to indicate this and sign the note. If the patient was actually seen by the physician, likely higher than 99212 as it seems there is a chronic problem not stable and prescription management. But I would not count the physician's work if he only discussed it with his nurse over the phone. 99211 may be performed by RN and documented as such. It's probably good medical practice to have the physician co-sign the RN note, but I don't believe it is REQUIRED.
In your second example, telephone (audio only) visit with nurse, 99441 is not the correct code. 99441-99443 are reserved for billable providers (MD, DO, PA, NP, CNM, etc.) 98966-98968 may be more appropriate for RN services depending on your state and the payor. The overseeing clinician goes on the claim. Please note "QUALIFIED health care professional" in the description. If your nurse is an LPN, and your state does not license LPN, then you definitely may not bill for the service.
98966 Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

Please note - there have been dozens of changes to the telehealth services. You may want to check with the carrier if 98966-98968 is even a covered service.
My personal 2 cents is if this was a one time thing, it's not worth the research required to even see if it is possibly billable.

Click to expand...

Thanks for the thoughtful reply. I appreciate the response for the 99211 visits. I guess I’m confused because the doc is not co-signing them but when there is MDM happening it seems like he should, but I haven’t found anything to support that it’s required as you stated above.

A few questions, I thought 98966-98968 were for qualified non physicians such as speech-language pathologists, physical therapists, occupational therapists, social workers, dietitians as stated in the description above the other phone visits 99441. In the situation above, the Medical Assistant or Nurse is the one talking to the patient. Neither of these people have NPI numbers so when we bill them in general, the supervising provider on the claim is the doctor and it goes out under his NPI number. So that seems like it wouldn’t work if I were to use 98966 because the doctor is on the claim and docs are supposed to use the 99441. Can you clarify that? Is that what you were referring to when you said if they are not licensed by the state?
 
I included a couple of links for references in my original answer. Yes, the definite original intention was 98966-96968 was for providers such as RD, OT, PT, SLP, CSW, etc.
SOME states, SOME carriers MIGHT allow a telephone service by RN to be billed with 98966-98968 under the supervising clinician. Specifically, question 12 in the 2nd link for New Mexico Medicaid states RN telephone call may be billed with 98966-98968.
12. Can Telephone Triage calls be billed using the CPT codes 98966-98968, when the service is provided by a Registered Nurse (RN), Licensed Practical Nurse (LPN) or Medical Assistant (MA)?
Answer: An RN can provide Telephone Triage calls when the RN is overseen by a physician, NP or PA. The Telephone Triage calls can be billed using CPT codes 98966-98968; the rendering requirement provider information on the claim must reflect the overseeing provider’s NPI and/or Medicaid Provider ID number.
The CPT codes 98966-98968 require a qualified health care professional for assessment and management. An assessment or management of care is not within standard of practice for an LPN and a MA is not required to be certified/licensed by the state of NM therefore is not recognized as a qualified professional

I cannot imagine any carrier allowing an MA to provide those telephone services. It is POSSIBLE a carrier will allow RN services to be billed that way; you would need to check carrier policy. If it is something that happens once a pandemic, I would not bother researching. If for some reason, your practice wants to provide this service on an ongoing basis, you would have to research each carrier and plan type to determine their policy about RN telephone services - both whether it is permitted, and whether it is covered. Don't forget it also needs the rest of the description - not from a visit in the past 7 days nor resulting in soonest available appointment. And the patient needs to request the service and be aware it is billed.
 
csperoni said:
I included a couple of links for references in my original answer. Yes, the definite original intention was 98966-96968 was for providers such as RD, OT, PT, SLP, CSW, etc.
SOME states, SOME carriers MIGHT allow a telephone service by RN to be billed with 98966-98968 under the supervising clinician. Specifically, question 12 in the 2nd link for New Mexico Medicaid states RN telephone call may be billed with 98966-98968.
12. Can Telephone Triage calls be billed using the CPT codes 98966-98968, when the service is provided by a Registered Nurse (RN), Licensed Practical Nurse (LPN) or Medical Assistant (MA)?
Answer: An RN can provide Telephone Triage calls when the RN is overseen by a physician, NP or PA. The Telephone Triage calls can be billed using CPT codes 98966-98968; the rendering requirement provider information on the claim must reflect the overseeing provider’s NPI and/or Medicaid Provider ID number.
The CPT codes 98966-98968 require a qualified health care professional for assessment and management. An assessment or management of care is not within standard of practice for an LPN and a MA is not required to be certified/licensed by the state of NM therefore is not recognized as a qualified professional

I cannot imagine any carrier allowing an MA to provide those telephone services. It is POSSIBLE a carrier will allow RN services to be billed that way; you would need to check carrier policy. If it is something that happens once a pandemic, I would not bother researching. If for some reason, your practice wants to provide this service on an ongoing basis, you would have to research each carrier and plan type to determine their policy about RN telephone services - both whether it is permitted, and whether it is covered. Don't forget it also needs the rest of the description - not from a visit in the past 7 days nor resulting in soonest available appointment. And the patient needs to request the service and be aware it is billed.
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Yes, I appreciate you citing your sources, thank you for that!

I did just check and it appears NJ does not require a license or certification for MA's, so I agree with you it is unlikely to be billable. The issue I am having is that there are multiple provider types in the office (MD, RN, MA, and now we got a PharmD). I wish this was one-off pandemic stuff, but it isn't. What is happening is the doctor will see the patient and his schedule is so busy he cannot fit them back in for 6 months, but he needs to see them sooner in order to monitor medication changes, etc. He has them come back in the month to follow up but schedules them with the RN, MA or PharmD. I am trying to figure this out and even you are saying its payer specific. I am mentally stuck on the signature requirements. I have not been able to find anything to support the doctor HAS to co-sign, but like you said above it would be a best practice. It has all been quite confusing, and I have never worked anywhere that utilized the ancillary staff so robustly. And anywhere I have worked previously, the doctor always signed off on anything that was done whether it was by the RN or MA or whatever. So this has all been new and confusing so far. I am still hung up on the MDM part too, when the patient has a med change relayed through the RN/MA, you are saying that could be billable as a 99211 even with only the RN/MA signature? The office notes normally do not indicate if the doctor physically saw the patient or not, but the doctor is normally in the office suite.

As an added bonus to this, all last year the office was telling patients these visits were free. So when I would bill the 99211 and they got hit with a copay, it added an additional layer of confusion for me with patient complaints. I kept wondering if I was supposed to even be billing them at all. Now what's happening is there is a new staff member taking over the billing for this office and the supervisor is training him and he's asking me the same questions I have been asking for the last two years. Sorry for the vent here, but it's just been a wacky week.
 
It seems you are asking multiple questions, with additional follow up questions. Let me try to address them individually.
1) The payor specific guidance relates to the telephone services, not the in person services.
2) In person may be billed 99211 for RN, LPN or MA carrying out a physician's order (BP check, etc.) If the pharmacist is an employee and staff of the physician, I think that may also qualify for 99211, but you should double check that.
3) No matter the level of MDM taking place, if the physician is not seeing the patient (in person or telehealth), you cannot use any E/M above 99211.
4) Regarding physician co-sign - sometimes state definition of scope of practice may require that. It is more of a compliance issue. Again, I personally have never seen in black and white that it is required, but I would strongly recommend it as a best practice.
5) The practice may decide to provide these services for free. Completely free. For all patients. You may not bill differently depending on the carrier. You may not routinely waive copays. If you want to provide the services for free, neither the patient nor the insurance may be billed.
6) In any practice I have worked, I educate the clinical staff that they should not be discussing financial concerns with the patient. That is what my properly trained billing staff is for. 7) My very own personal opinion is it sounds like the practice needs an NPP (PA, NP) if the physician is so busy he doesn't have enough time to treat his patients. A properly utilized NPP can relieve so many of these issues. It provides better, quicker care and communication to the patient and the services are billable. Otherwise, I would consider closing your practice to new patients.

Good luck!
 
csperoni said:
It seems you are asking multiple questions, with additional follow up questions. Let me try to address them individually.
1) The payor specific guidance relates to the telephone services, not the in person services.
2) In person may be billed 99211 for RN, LPN or MA carrying out a physician's order (BP check, etc.) If the pharmacist is an employee and staff of the physician, I think that may also qualify for 99211, but you should double check that.
3) No matter the level of MDM taking place, if the physician is not seeing the patient (in person or telehealth), you cannot use any E/M above 99211.
4) Regarding physician co-sign - sometimes state definition of scope of practice may require that. It is more of a compliance issue. Again, I personally have never seen in black and white that it is required, but I would strongly recommend it as a best practice.
5) The practice may decide to provide these services for free. Completely free. For all patients. You may not bill differently depending on the carrier. You may not routinely waive copays. If you want to provide the services for free, neither the patient nor the insurance may be billed.
6) In any practice I have worked, I educate the clinical staff that they should not be discussing financial concerns with the patient. That is what my properly trained billing staff is for. 7) My very own personal opinion is it sounds like the practice needs an NPP (PA, NP) if the physician is so busy he doesn't have enough time to treat his patients. A properly utilized NPP can relieve so many of these issues. It provides better, quicker care and communication to the patient and the services are billable. Otherwise, I would consider closing your practice to new patients.

Good luck!
Click to expand...
I can’t thank you enough for the thorough explanations you have provided, it has really helped me straighten out my thoughts on the whole situation. Thank you!
 
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