Wiki 99211 w/85610 and 36416

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kbarron

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:(I am ready to tear my hair out. I have explained to the office that they cannot routinely charge a 99211 for all the anticoagulation checks. The MD insists that he reviews everyone that is done.He is insisting that I bill it out. I reviewed a couple of the notes as follows: INR was done in office 3.4 pt has taken 4 mg good on 3.5 recheck in a week, today's INR 3.0 recheck in 1 wk..I have not been putting the 99211 on claim because this is not adequate documentation. Is there a link to verify the guidelines for this situation? Thanks for any help.
 
I wanted to know if anyone wanted to help me out with this dilema. I would like to find in writing that states the criteria for 99211. I don't see where the visits qualify for 99211.
 
Kathleen Mueller did an excellent article for Decision Health in 2002 Feb 11 and Feb 18 re this issue and stated emphatically that a 99211 could not be charged for a blood draw encounter. BTW she was the compliance officer for CMS at the time. I have found numerous other articles that also support that this is not done. A code for the draw exisits with 36415 or 36416 and that is the appropriate charge. All work perforemed by the nurse is part of the blood draw and is encompassed with that code.
 
mitchellde said:
Kathleen Mueller did an excellent article for Decision Health in 2002 Feb 11 and Feb 18 re this issue and stated emphatically that a 99211 could not be charged for a blood draw encounter. BTW she was the compliance officer for CMS at the time. I have found numerous other articles that also support that this is not done. A code for the draw exisits with 36415 or 36416 and that is the appropriate charge. All work perforemed by the nurse is part of the blood draw and is encompassed with that code.
Click to expand...

Hi Michelle, I am unable to access the publication. Is there anyway this could be forwarded? Thanks
 
I wish I could, it was an article for Decision Health which is a paid for subscription and they have very strict rules regarding copying and forwording articles. While we can pass on the information we cannot send copies. If you do an internet search for the 99211 with the 36415 you should be able to locate appropriate information.
 
I found this from a consulting service on th Web which is almost to the word from the Decision Health article:
News Articles
ARE YOU GETTING PAID WHAT YOU COULD FOR BASIC EVALUATION AND MANAGEMENT SERVICES?
1/10/2005

Evaluation and Management Services represent those services rendered by Physicians and Non Physician Practitioners (NPP) in both the outpatient (clinic, office and other) and inpatient setting. All services rendered by a physician, NPP and their staff should be reflected in their documentation and reimbursed accordingly. While most Evaluation & Management services rendered are captured through the documentation and billing process, many physician practices/clinics fail to capture revenue opportunities for basic medically necessary services, resulting in lost revenue.

Failure to capture these billing opportunities, even for the most basic of services, such as a patient visit for a follow up blood pressure check or reading a PPD, results in lost revenue. These services can and should be reimbursed.

Billing Current Procedural Terminology (CPT) code 99211 where appropriate can result in increased revenue:

Let’s say your practice/clinic sees 10 patients a week for one of these basic medically necessary services. Assuming your practice is a full time practice that amounts to approximately 520 encounters annually, billing these basic services would result in additional revenue of over $10,000 per year. Specific payment amounts will vary by payer, but the average unadjusted 2004 payment from Medicare for visit code 99211 is $21 for physician offices and $51.43 for outpatient hospital services.

What CPT 99211 represents:

This code as defined by the American Medical Association represents an established patient 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 problem(s) are minimal. Typically, minutes are spent performing or supervising these services.

Many of these services are rendered by the nursing staff and reimbursed based on rules inherent in third party payers’ policy and the Centers for Medicare and Medicaid incident-to policy. However, each payer may differ. These visits are frequently referred to as “nurse visits”.

Physicians can report 99211, but it is intended to report services rendered by other individuals in the practice, such as a nurse or other staff member.

Examples of office/clinic visits generally billable using 99211:

*
A blood pressure evaluation for an established patient whose physician requested a follow up visit to check the blood pressure
*
Refilling medication for a patient whose prescription has run out to hold him over until her can get an appointment
*
Prescription follow up when urinalysis is positive
*
Discussion with patient in person following laboratory tests that indicate the need to adjust medications or repeat order of tests
*
Flushing a chemotherapy port not associated with administration of chemotherapy
*
Follow up PPD/tuberculin test reading
*
Suture removal following placement by a different physician/physician group
*
Visit for instructions/patient education on how to use a peak flow meter
*
Dressing change for an abrasion/injury

Examples of services generally not billable using 99211:

 *
Blood draw - should be billed using CPT 36415
*
Laboratory tests - the lab performing the test should bill the appropriate codes
*
Chemotherapy injections - bill using the appropriate chemotherapy injection code(s)
*
Assessment or flushing of a vascular access port prior to administration of chemotherapy. This is integral to the chemotherapy administration and is not separately billable
*
Monitoring of cardiology tests, such as thallium stress tests, where such monitoring is inherent in the performance of the test
*
Injection of medication - use CPT drug administration code and drug code
*
Influenza vaccination - use vaccination code and administration code only

What you should know when rendering service/billing 99211:

*
Visits must be face to face and therefore telephone calls do not count
*
The patient must be an established patient who has received professional services from the physician or another physician of the same specialty, in the same group practice within the past three years. Therefore, CPT code 99211 can not be reported for services provided to a patient who is new to the physician.
*
There are no specific documentation guidelines from Medicare for 99211, but complete documentation to support the services should be present. It is a good practice to include the reason for the visit, a brief history and assessment, all services rendered, and any plany and/or follow up. Payers may differ in their requirements. The typical note is 2 to 4 sentences.
*
For many third party payer’s, nurses can bill these services whether or not the physician is in the office. However, Medicare has specific rules about incident-to services. For example, if a patient comes in for symptoms related to a sore throat and the nurse documents the patient’s history, documents the results of the quick strep test and notes the assessment and plan - this is not billable to Medicare as incident-to as it is a new problem. Follow Medicare’s incident-to rules.
*
Service must be separate from other services performed on the same day, for example, if a nurse provides instructions following a physician’s minor procedure or takes a patients’ vital signs prior to an encounter with the physician, 99211 should not be reported for these activities because they are considered part of or integral to the E&M service already being provided by the physician.

Keep in mind that some services are more appropriately reported with a CPT code other than 99211. And, not every encounter has a clinical indication that supports a separate visit code.

There is no “one set” of specific guidelines for when to use or not use 99211, each individual payer may differ. Use this information as a guide to determine the appropriate uses of 99211 in your setting based on your practice.

Payers periodically issue examples and guidelines regarding the proper use of certain codes. Keeping current with up to date knowledge regarding coding practices can improve your reimbursement and help to avoid compliance issues.
 
is it allowable to charge 99211 with modifier 25 and 36415 when we are monitoring protimes in our internal medicine office. We are keeping a log of bp, dosage, and results for doctors to review and instruct on for each patient.
 
Of interest, Healthcare Business Monthly April 2015 pp. 26 & 27 lists 2 examples of visits and says they are not billable as 99211. Both examples are listed on Debra's source doc as "generally billable" (notice the author couches with generally billable & not billable) & this 4/2015 article says no. One is the UA with prescription & the other is a patient who had a medication change d/t results of a test. Also, you have to be careful about that dressing change for injury because it could be post-procedural care for an injury under a global period. It is very confusing.
Linda Tonyes RDN, LDN, CPC-A
 
FYI. There has been a span of ten years from when the article I post was authored and this Healthcare Business Weekly article was posted. A lot has changed in those ten years.
 
Thank you

Debra:
Thank you for the thoroughness of your responses. I have found many of your posts extremely helpful for my job. I've been coding for 3 years, but I continue to learn something new all the time. In my practice we do use the 99211 and I have always found it to be used appropriately.
Suzanne
 
This is old from the AAFP but I still think the info is useful ... Hope this helps!
http://www.aafp.org/fpm/2007/1100/p15.html#fpm20071100p15-sa3

Prothrombin time testing with 99211


Q

I am considering adding CLIA-waived fingerstick prothrombin time testing to my outpatient clinic services. In addition to charging for the fingerstick (36416) and the test (85610), can I also bill a level-I office visit to cover my nurse's involvement in obtaining the specimen, running the test, processing the results and adjusting the warfarin dose?


A

It depends. If your nurse provides a medically necessary E/M service to the patient and if your payer has a policy that allows the reporting of E/M services by nurses under the supervision of a physician (e.g., Medicare's incident-to billing rule), you may report a 99211 in addition to 36416 and 85610. Check with your private payers to determine whether they have an incident-to rule in place.

Reports from Medicare audit contractors have noted that the documentation for these types of visits often fails to indicate medically necessary E/M services, which has led to the denial of 99211 services. To meet the requirements for a 99211 visit, nurses should document the reason for the visit, changes in the patient's history, medications or diet, instructions for continuing the physician's plan of treatment, and any discussion that occurs. For more guidance, see ?Understanding When to Use 99211,? FPM, June 2004, and ?The Ins and Outs of ?Incident-To? Reimbursement,? FPM, November/December 2001.

You should also check which payers reimburse anticoagulation management under codes 99363 (for the first 90 days of therapy) and 99364 (for each subsequent 90 days of therapy). These codes include the physician review and interpretation of test results, patient instructions, dosage adjustment (as needed) and ordering of additional tests. When reporting 99363 and 99364, you may not report an E/M office visit code. (Note that Medicare does not reimburse the anticoagulation management codes in 2007, and the proposed rule for 2008 still lists them as noncovered.)
 
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