Minimal E/M service on an established patient

August 10th, 2009 - Codapedia Editor
Categories:   Coding   Compliance   Primary Care|Family Care  

Nurse visits are services provided by nursing staff in a physician office under the general supervision of a physician.  The physician does not typically have a face-to-face service with the patient.  These services are billed with code 99211.  The CPT® book defines 99211 as: Office or other outpatient visit for the evaluation and management of an established patient, that may not required the presence of a physician.  Usually, the presenting problem(s) are minimal.  It is unusual for physicians or Non-Physician Practitioners to use this code.  Services provided by nurses and other licensed and non-licensed non-providers are subject to state rules regarding scope of practice.

Although we describe these as "nurse visits" a medical assistant may provide this service.

    Like all services, nurse visits must be medically necessary.  Beware of automatically  billing for a nurse visit along with another service, such as an allergy injection.  Bill for a nurse visit only when a distinct and separate service is performed.  Do not bill  a nurse visit in place of another CPT® code, which more accurately describes the service, such as venipuncture or an injection.  Use the CPT® code that most accurately describes the service.   Both CPT® and Medicare require you to bill for the service that most accurately describes the code and if administration of the flu vaccine is what is done, bill that code.

    It is a mistake to bill a nurse visit in addition to another service.  If a patient comes in for venipuncture, bill only for the venipuncture.  If the patient comes in for an immunization, bill only for the administration of the immunization, and the serum, if purchased by the hospital.   Just because the nurse documents the vital signs, doesn't mean it should be billed as a nurse visit.

    When billing Medicare for nurse visits, all of the requirements for billing incident to services must be met.  Along with other rules, incident to services are only allowed in place of service office (11).  Review the Medicare rules for incident to billing.  Although 99211 is provided under the general supervision of a physician, for Medicare patients, the incident to requirements include the provision that physician or NPP (under whose provider number the service is being billed) must be in the suite of offices when the service is performed.  This is only one of the incident to provisions.  Read the Codapedia article on incident to services.

    Although the reimbursement for 99211 is low, physician practices bill this code at a high volume, making it both a compliance and revenue issue.

 Only a brief, SOAP note is needed.  For the subjective, document the reason for the visit and the patient’s description of how they are doing.  In the objective, document the patient’s vital signs and any relevant labs.  The assessment and plan can be separate or combined, and should include any verbal direction from the physician at that visit.

    What about coumadin checks?  If the patient comes in just to have the blood drawn, and the nurse or medical assistant later calls the patient to adjust their coumadin dose, this is NOT a billable service.  There is no payment for phone calls, and the blood draw earlier in the day does not represent a nurse visit.  If the patient comes in for their lab work, and the result is known prior to the patient leaving the office, and the nurse or MA gives them their lab result and adjusts their coumadin dosage, this may be a reportable service.  It must be medically necessary, be a face-to-face service and be appropriately documented. The adjustment is usually made in consultation with the physician, or according to a protocol.  Some payers have questioned the medical necessity for billing a 99211 if there is no change in medication.   For Medicare patients, it must meet incident to guidelines.


Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.

Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....

Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association