Wiki Re: 99211

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RAMONA!

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Re: 99211

If anyone, or everyone, would share a little info with me re: the situation I have in the Free Clinic for which I volunteer a few hours each week about 99211:

This being the code of course used most frequently for the Nursing Staff, it seems to be regarded as not too important. However, from my view, I need it to be correct. Here is the question I need answers for before I set my Volunteer Foot down; I need to know whether 99211 must have a diagnosis code in the chart in order to be coded correctly?

The Nurses have been submitting a Billing Slip with sometimes a diagnosis code on it and sometimes not. I may be able to discern that they did a B/P check, and I know that is 401.9. But when I open the Chart, it reads "no diagnosis."

They have recently decided that I will use V65.8 as the diagnosis code for their activities; however, inside the Chart is continues to read, "no diagnosis."

Can this legally happen?

Thanks to anyone with some information.
 
In order to bill for 99211 (following CMS's incident-rules), the service must be performed under the supervision of the physician who will determine the diagnosis and the treatment plan, which includes providing a nurse visit such as the 99211. A nurse cannot provide a diagnosis, it must come from the physician. If you're not billing, then certainly from a patient care perspective, there should be a reason for visit in the patient's chart.
 
Yes, agree with Pam's response above. The nursing staff should only be following physician orders, so you'd need to look for that order to get the diagnosis. Nursing staff would not independently diagnose the patient or be expected to document it, other than if they were to just take it from that same order.
 
Re:99211

Thank your for your responses.

I am understanding that there must be a "continuation order" from the physician to validate a nurse contact 99211 charge, and that diagnosis code is the code I would use for billing; but, there must be a diagnosis to validate the CPT code. Please correct me if I am wrong.

I am finding that 99211 is not simple, maybe not even straightforward.

Thank you kindly
 
When you say that you know when they do a BP check and that is a 401.9... I am a little concerned about that. A nurse could be performing a BP check for a number of reasons, the patient may not have diagnosed HTN at all. Pam is correct in that the dx must be rendered by the physician. The RN must document the reason for the encounter, we always made it mandatory that the nurse also document the date of the visit where the provider diagnosed the condition and indicated that the plan of care would include a follow up visit by the nursing staff.
 
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