Wiki Documentation requirements for 99211

[jenne4]

I need some help with the minimum requirements for nursing documentation to charge 99211. We have an outpatient infusion center where patient's are coming in for treatment by a physician (billed separately through that physician's office) our nurses are evaluating, prepping, and monitoring the patient. The dept wants to charge 99211 for the nursing services and the charge for the medications used. Currently the nurses are documenting vital signs and a sentence that the procedure was performed. What are the minimum documentation requirements to charge 99211? Should they also be documenting pain scale and/or any other evaluations?

 

[thomas7331]

99211 requires that the staff is performing a specific E/M service that was ordered by the physician as part of the plan of care for the patient. It shouldn't be billed for nursing services that are an integral part of another procedure, such as an infusion. In order to bill 99211, you would need a physician's order for the nurse to evaluate the patient for a specific reason that is not related to the other services performed on that date - it can't be billed simply for the vitals and monitoring of the patient before or during the infusion.

The Medicare contractor where I work publishes an excellent job tool for the requirements for billing 99211 which you can find here: PROCEDURE CODE 99211 JOB AID