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Blood Pressure check Coding

  1. #1
    Smile Blood Pressure check Coding
    Exam Training Packages
    We have a nurse that Blood Pressure check on an established pt. The patient had HTN. But the nurse did not do vitals, no advice documented. No exam or history documented. Can this still be 99211? I don't think so. But how would you code this encounter? Help.

  2. #2
    Columbia, MO
    You say she did not do vitals but did she do a bp? did she document in the chart? If so the yes it can be a 99211 as long as a physician was within the office suite at the time of the visit.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Default Blood Pressure check
    Here it is...we are not sure if the doctor was in the office. The documentation is very scant, that is the problem here. What it looks like is that this is an established patient that stopped by the office to have his blood pressure checked and was found to have HTN. What do think?

  4. #4
    Columbia, MO
    HMMMMMMMMMM.... NO. The nurse cannot diagnose HTN only the provider can do that and for the nurse to be able to charge a 99211 she has to be following up on an treatment plan already established by the physician.. no matter who the payer is.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    Default Blood Pressure Check
    I agree with you. But how do I code this encounter?

  6. #6
    Default Blood Pressure check
    Thanks Debra. I appreciate your skill and time that you take to answer me questions. You are really helping all of us coders out in the world.

  7. #7
    What about 796.2 (Elevated BP w/o diagnosis of HTN)? Could you not bill that w/99211?

  8. #8
    Default Blood Pressure check
    You changed your picture. Elevated BP was not in the note, and still a nurse can not diagnose a patient. It was scant documentation. I did not attached a code, saying it was "insufficient documentation" and "nurses can't diagnose."

  9. #9
    Thumbs up
    Yes I did!
    You did the right thing, then. Perhaps in the future they'll take better notes.

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