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99211 with Coumadin Checks

  1. #1
    Default 99211 with Coumadin Checks
    Medical Coding Books
    I know that this is an old subject but I have to re-visit it again. It is concerning the medical necessity of this billing scenario - 99211, 85610 AND 36416.

    There is great documentation for the 99211 each and every time - lots of questions by the nurse, including vitals and inspection of the skin - but is it actually necessary each and every time, or it this just something to increase revenue?

  2. #2
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    in 2002 Feb 11 Kathleen Mueller who was the CMS compliance officer wrote an article for Decision Health regarding the usage of the 99211. One of the things she stated was not allowed was using the 99211 to bill for a blood draw. You have a code for this activity either 36415 or 36416. Inherent in those codes are all the services required by the nurse for that blood draw.
    This is no different from the physician that has an eval and performs the joint injection and orders the patient ot reurn in a week for a repeat inject. The physician on the 2nd injection cannot charge the OV and the injection he gets the injection only.
    So for the blood draw encounter, the physician has evaluated the patient and has charged the E&M and has ordered the patient to return for a repeated blood draw. There is nothing more being performed that what was ordered by the physician and there is a code for the blood draw. Therefore we cannot charge the 99211.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    Trailblazer/Medicare has issued out specific guidelines on what supports 99211 in addition to the 85610. Baisically there must be separate work above and beyond the work already included/reported with 85610. If so, then the 99211-25 can be coded to capture/report this separate work. Here is a paste of the specific guideline


    The table below contains elements that would constitute adequate documentation of a code 99211 service in selected clinical circumstances:

    Adequate Documentation for Code 99211
    Prothrombin time evaluation for patients on chronic warfarin anticoagulation

    1. Reason for the visit. A physician visit is not routinely necessary to draw blood for prothrombin time or other laboratory tests. Therefore, the documentation for code 99211 or any other E/M code in this circumstance must demonstrate a need for clinical E/M. In this case, services that would serve to demonstrate that E/M was performed include an evaluation of significant new symptoms (such as excessive bruising or hemorrhage). Alternatively, for patients who have no new clinical concerns, documentation that contemporaneous laboratory values were obtained, reviewed and used to guide current and/or future therapy documents that a separately payable E/M service has been performed.

    2. Current medications listed (with notation of level of compliance).

    3. Indication of doctor's evaluation of the information about signs/symptoms and laboratory test result and his management recommendation.

    4. Identity and credentials of provider(s) as listed in text above.

  4. #4
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    Quote Originally Posted by sbicknell View Post
    Trailblazer/Medicare has issued out specific guidelines on what supports 99211 in addition to the 85610. Baisically there must be separate work above and beyond the work already included/reported with 85610. If so, then the 99211-25 can be coded to capture/report this separate work. Here is a paste of the specific guideline


    The table below contains elements that would constitute adequate documentation of a code 99211 service in selected clinical circumstances:

    Adequate Documentation for Code 99211
    Prothrombin time evaluation for patients on chronic warfarin anticoagulation

    1. Reason for the visit. A physician visit is not routinely necessary to draw blood for prothrombin time or other laboratory tests. Therefore, the documentation for code 99211 or any other E/M code in this circumstance must demonstrate a need for clinical E/M. In this case, services that would serve to demonstrate that E/M was performed include an evaluation of significant new symptoms (such as excessive bruising or hemorrhage). Alternatively, for patients who have no new clinical concerns, documentation that contemporaneous laboratory values were obtained, reviewed and used to guide current and/or future therapy documents that a separately payable E/M service has been performed.

    2. Current medications listed (with notation of level of compliance).

    3. Indication of doctor's evaluation of the information about signs/symptoms and laboratory test result and his management recommendation.

    4. Identity and credentials of provider(s) as listed in text above.
    And if you will notice they call it a physician encounter not a nursing encounter.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
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    Ladies - I actually submitted this question to TrailBlazers. They do allow 99211 for Protime/INR checks performed by the nurse provided the documentation supports the service.
    Lisa Bledsoe, CPC, CPMA

  6. Default
    Lisa, I agree and those were TB guidelines I pasted from the E&M manual

    mitchellde, your statement is confusing. The guidelines I pasted are 99211 guidelines for nurses..not for physicians
    Last edited by sbicknell; 06-03-2010 at 06:03 PM.

  7. #7
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    I included in my question to TrailBlazer the link for their guidelines and the link that was posted for WPS, which were contradictory. They explained that the difference is that the WPS link was in relation to their CERT audits showing lack of supporting documentation. The TB link shows what they expect the documentation to contain in order to be billable by ancillary staff.
    Lisa Bledsoe, CPC, CPMA

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