The only real requirement for a 99211 visit is a chief complaint.
Is the patient coming in just to have BP checked because s/he is being followed for HTN? Then it is probably a 99211.
Or is the patient coming in for an injection, and the nurse takes vitals because they always do this before the injection? Then you code only the injection and don't code any E/M (because you do not have a significant separately reportable E/M service)
Or is the patient coming in for an injection, and "by the way" has a stuffy nose ... so the nurse takes vitals, asks about fevers or other associated symptoms and says "take two aspirin and call again if you get worse." Here you have a separately reportable 99211 E/M (don't forget your -25 modifier) and an injection administration.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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