Billing 99211 Its not a freebie
November 9th, 2018 - BC Advantage
It seems like a simple code to bill, but CPT 99211 (established patient office visit) is by no means a freebie when it comes to documentation and compliance. This lowest level office visit code is sometimes called a "nurse visit" because CPT does not require that a physician be present for an encounter that is billed with 99211. Even so, 99211 does require key components and documentation.
In this tip, we'll take a look at 99211 and some of the reasons it gets billed without proper documentation or, in some cases, billed when no code is actually billable. The very low requirements specified by CPT may actually lead some practices to freely report 99211 with less documentation rigor than other E/M services.
CPT describes 99211 as: An "office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services." The national Medicare average payment for 99211 is approximately $21.96.
But these requirements still apply to 99211:
- A chief complaint. This is the reason for the encounter, given as a concise statement typically in the patient's own words. Like any problem-oriented E/M services, a note to support 99211 needs a chief complaint.
- Some sort of management. There are no key components required for 99211, but even if the service is a blood pressure check, the documentation should show what was done and why, in a way that makes sense given the chief complaint.
- Incident-to rules. For Medicare and payers that follow Medicare's incident-to rules, 99211 is almost an incident-to service by default. Incident-to billing allows a non-physician to bill for a service under the physician's identifier at the physician's contracted fee schedule rate.
More on incident-to: Because it does not require the presence of a physician, 99211 is typically performed by a nurse or other non-physician. The lowest level of service a physician typically bills is 99212. However, to meet incident-to, the usual factors apply to 99211 - no change to the plan can be made and the service must be incidental to a physician's existing treatment plan. The supervising physician (in the same office suite) will sign in addition to the nurse or other rendering provider.
Improper uses of 99211: It's not a 'freebie'
So far, so good - we've established that 99211 is billable with much less documentation required than any other E/M service, and covered incident-to. What about improper uses of 99211? For example, allergen injections for immunotherapy and corticosteroid injections for joint pain are common minor procedures and some providers mistakenly have 99211 reported alongside the injection code.
This is tricky, because there are situations where this could be medically necessary and supported, but those are few and far between. First, just like any minor procedure, the CPT code for an allergy injection includes the typical pre- and post-procedure work. So 99211 would require modifier 25 (separate, significant E/M service, same patient, same day) to be appended.
Simply making the nurse or allergist take patient's vitals and adding a few notes into the record won't justify appending modifier 25 to get 99211 separately billed; such a move would not meet the requirements for modifier 25. However, if there is actually a separate problem or a significant complication like an unexpected reaction to the allergen in the immunotherapy example, or a joint infection following the steroid shot, there's now a case for modifier 25 and 99211 or a higher level of service. Unfortunately, such a problem would likely require the physician's presence and incident-to could not be met.
Therefore 99211 is best used in those cases where no other service can be billed, but the problem does not rise to the level of needing a physician to see the patient. To be optimal from a revenue standpoint, 99211 is best utilized under incident-to so the code can be billed under a supervising physician.
This Week's Audit Tip Written By:
Grant Huang, CPC, CPMA
Grant is the Director of Content for our parent organization, DoctorsManagement.
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)COVID Vaccine Coding Changes as of November 1, 2023October 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 ServicesOctober 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),....Can We Score Interpretation of an EKG Towards E/M Medical Decision Making?October 10th, 2023 - Aimee Wilcox
When EKGs are performed in the facility setting or even in the physician's office, what are the requirements for reporting the service and who gets credit for scoring data points for Evaluation and Management (E/M) medical decision making (MDM)? Let's take a look at a few coding scenarios related to EKG services to get a better understanding of why this can be problematic.Accurately Reporting Signs and Symptoms with ICD-10-CM CodesOctober 5th, 2023 - Aimee Wilcox
Coders often find themselves unsure of when to report a sign or symptom code documented in the medical record. Some coders find their organization has an EHR that requires a working diagnosis, which is usually a sign or symptom, be entered to order a test or diagnostic study or image. Understanding the guidelines surrounding when signs and symptoms should be reported is the first step in correct coding so let's take a look at some scenarios.The 2024 ICD-10-CM Updates Include New Codes for Reporting Metabolic Disorders and Insulin ResistanceSeptember 19th, 2023 - Aimee Wilcox
Diabetes is a chronic disease that just seems to consistently be increasing instead of improving resulting in a constant endeavor by medical researchers to identify causal effects and possible treatments. One underlying or precipitating condition that scientists have identified as a precipitating factor in the development of diabetes is insulin resistance, which is a known metabolic disorder. As data becomes available through claims reporting, additional code options become possible with ICD-10-CM.Documenting and Reporting Postoperative VisitsSeptember 12th, 2023 - Aimee Wilcox
Sometimes we receive questions regarding documentation requirements for specific codes or coding requirements and we respond with information and resources to support our answers. The following question was recently submitted: Are providers required to report postoperative services on claims using 99024, especially if there is no payment for that service? What documentation is required if you are reporting an unrelated Evaluation and Management (E/M) service by the same physician during the postoperative period? Understanding Gastroesophageal Reflux Disease and ICD-10-CM CodingAugust 22nd, 2023 - Aimee Wilcox
Gastroesophageal reflux disease or GERD for short, is a disease that impacts millions of Americans on a weekly basis. Symptoms are uncomfortable, as are some of the tests used to diagnose it, but understanding the disease, tests, and treatments helps us better understand how to code the disease using ICD-10-CM codes.