Wiki 99211

[k.ellias]

Hello,

I'm not sure if a 99211 e/m code would be appropriate for the following situation:

Documentation states, "Patient slipped on the ice and put their right hand out to catch themselves. Patient reported that their thumb bent all the way back to their wrist. It is swollen and painful and it hurts to move it. Injury occurred 20 minutes ago. Patient also reports numbness. Patient agrees to be seen in Emergency Room for further evaluation."

No "work" was done, just reported what the patient told them and sent them to the emergency room. Would a 99211 still be appropriate?

Thank you!

 

[mitchellde]

Was this a physician note?

 

[k.ellias]

No, this was a nurse note

 

[thomas7331]

This is not a billable service because it doesn't meet the 'incident to' requirements. Nurse visits can only be billed when they are providing a service that was ordered by the physician as part of a plan of care, and the physician would have had to evaluate the patient for this problem first.

 

[mitchellde]

Yes as a nurse encounter this cannot be billed and honestly should not have been performed. A nurse lacks the necessary credentials to advise a patient on proper treatment without a physician examination.

 

[k.ellias]

Thank you for your input!