http://www.aafp.org/fpm/2004/0600/p32.html
Basic guidelines
The following guidelines can help you decide whether a service qualifies for 99211:
The patient must be established. According to CPT, an established patient is one 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. Code 99211 cannot be reported for services provided to patients who are new to the physician.
The provider-patient encounter must be face-to-face. For this reason, telephone calls with patients do not meet the requirements for reporting 99211.
An E/M service must be provided. Generally, this means that the patient’s history is reviewed, a limited physical assessment is performed or some degree of decision making occurs. If a clinical need cannot be substantiated, 99211 should not be reported. For example, 99211 would not be appropriate when a patient comes into the office just to pick up a routine prescription.
The presence of a physician is not always required. Although physicians can report 99211, CPT’s intent with the code is to provide a mechanism to report services rendered by other individuals in the practice (such as a nurse or other clinical staff member). According to CPT, the staff member may communicate with the physician, but direct intervention by the physician is not required.
Medicare’s requirements on this point are slightly different: While the physician’s presence is not required at each 99211 service involving a Medicare patient, the physician must have initiated the service as part of a continuing plan of care in which he or she will be an ongoing participant. (To some carriers, this means that the physician must see the patient at least every third visit.) In addition, the physician must at least be in the office suite when each service is provided. The reason for this difference is that Medicare considers these services to be an integral although “incidental” part of the physician’s professional service. According to Medicare and most third-party payers, incidental services should generally be reported under the name and billing number of the physician or other professional in the office suite when the service is provided. Note, however, that the services can also be billed “incident-to” other health professionals, such as physician assistants or nurse practitioners.
No key components are required. Unlike other office visit E/M codes – such as 99212, which requires at least two of three key components (problem-focused history, problem-focused examination and straightforward medical decision making) – the documentation of a 99211 visit does not have any specific key-component requirements. Rather, the note just needs to include sufficient information to support the reason for the encounter and E/M service and any relevant history, physical assessment and plan of care. The date of service and the identity of the person providing the care should be noted along with any interaction with the supervising physician.
