Wiki 99211

[alp.jeffrey]

I'm wanting to get some info on 99211. I have all the basic info but I need something about documentation in the office visit. I work in Urology and we bill catheter removals or teaching visits with a 99211. The visits are done by a nurse or MA. I see where they need to put documentation to justify why the patient is there essentially. Sometimes they end up doing a bladder scan (51798). They basically are putting an order in the visit for that service.
If an order is placed, does this need to be changed to a 99212 since the physician is in office and told the nurse/MA to do the bladder scan but he doesn't actually see the patient but does see the results of the scan?
And the primary biller on the claim, is it the nurse that does the visit? Our EMR has Primary biller, Primary provider, Referring. They've been putting the nurse/MA in as primary provider and the patient's physician as primary biller. Will an insurance process the claim if the primary provider isn't a physician?

Hopefully this makes sense. Maybe I'm thinking too deeply into this. Any help is very much appreciated.

 

[csperoni]

It seems like you're asking several questions here. Let me try breaking it down.
1) Documentation. Whoever is providing the service should document what took place - just like any other E&M service. 99211 does not require a whole lot in terms of documentation due to the low level. Some MACs have stated incident-to 99211 ancillary staff visits should be co-signed by the supervising clinician.
2) Ordering bladder scans. A nurse (RN/LPN) or MA cannot order tests. Tests must be ordered by a physician or ACP (PA, NP or other CNS). It may be done verbally where the physician simply talks to the nurse or reviews records and gives a verbal order, or the physician may document. Best practice (and some practices/facilities require it) is for the ordering clinician to sign off on the order and results.
3) Level of visit if test ordered. If the physician did not personally see/evaluate the patient, 99211 is the highest level that may be billed by ancillary staff. Don't forget that medical necessity is the overarching criteria of all E&M services. So even if the provider does stick his head in the room, that does not automatically mean bill 99212. If after speaking with nurse or reviewing records, the physician determines they need to personally evaluate the patient, then bill whatever E&M level is supported.
Don't forget that 99211 & 51798 are NCCI edits that may be overridden with a modifier. You'll want to ensure records justify 99211-25 along with 51798.
4) Primary biller vs Primary provider vs referring. That is something unique to each EMR system - what they label certain fields. In my system, it's "billing provider, performing provider and referring provider." Most likely "primary provider" is intended to be the person who actually rendered the service (nurse/MA), and "primary biller" would be the person whose name is submitted on the claim (supervising onsite physician). You should confirm with your EMR but the "primary provider" listed is likely nowhere on a submitted claim.

 

[alp.jeffrey]

It seems like you're asking several questions here. Let me try breaking it down.
1) Documentation. Whoever is providing the service should document what took place - just like any other E&M service. 99211 does not require a whole lot in terms of documentation due to the low level. Some MACs have stated incident-to 99211 ancillary staff visits should be co-signed by the supervising clinician.
2) Ordering bladder scans. A nurse (RN/LPN) or MA cannot order tests. Tests must be ordered by a physician or ACP (PA, NP or other CNS). It may be done verbally where the physician simply talks to the nurse or reviews records and gives a verbal order, or the physician may document. Best practice (and some practices/facilities require it) is for the ordering clinician to sign off on the order and results.
3) Level of visit if test ordered. If the physician did not personally see/evaluate the patient, 99211 is the highest level that may be billed by ancillary staff. Don't forget that medical necessity is the overarching criteria of all E&M services. So even if the provider does stick his head in the room, that does not automatically mean bill 99212. If after speaking with nurse or reviewing records, the physician determines they need to personally evaluate the patient, then bill whatever E&M level is supported.
Don't forget that 99211 & 51798 are NCCI edits that may be overridden with a modifier. You'll want to ensure records justify 99211-25 along with 51798.
4) Primary biller vs Primary provider vs referring. That is something unique to each EMR system - what they label certain fields. In my system, it's "billing provider, performing provider and referring provider." Most likely "primary provider" is intended to be the person who actually rendered the service (nurse/MA), and "primary biller" would be the person whose name is submitted on the claim (supervising onsite physician). You should confirm with your EMR but the "primary provider" listed is likely nowhere on a submitted claim.

Thanks for all this great info! It really has answered all my many questions.