Nurse visit with limited physician time in the room can it be coded higher than a 99211?

[cedwards]

Can this visit be coded as a 99213?

An established patient comes to the office with complaints of urinary burning and frequency. The nurse takes a focused history, reviews the medical record, discusses the situation with the physician and orders a urinalysis. The nurse then presents the findings to the physician, who briefly enters the room, reviews the plan with the patient, writes a prescription for an antibiotic. The nurse documents the encounter in the medical record (includes in documentation that the provider entered the room and communicated the plan) and the physician or APP co-signs the documentation.

Thank you in advance for your feedback.

Christina

 

[thomas7331]

A E&M service that includes a face-to-face with the physician does usually warrant billing a 99212 or higher, however, the physician or NPP would need to document their own portion of the service - co-signing the nurse's notes is not sufficient for this. If there is only documentation from the nurse, then you can only bill a nurse visit.

 

[cedwards]

A E&M service that includes a face-to-face with the physician does usually warrant billing a 99212 or higher, however, the physician or NPP would need to document their own portion of the service - co-signing the nurse's notes is not sufficient for this. If there is only documentation from the nurse, then you can only bill a nurse visit.

Thank you!