Forum - Questions & Answers
99211 not being paid
I have been getting paid only on 36415 and not on the 99211 with a reason of "Pymt included in allow for other svc".
This is not only happening with one insurance company, I am seeing it often. How can I get paid for the nurse visits?
Thank you,
Joyce
re: 99211 not being paid
Are you using a 25 modifier on 99211? Some carriers require the 25 when performing any other service.
re: 99211 not being paid
I'm sorry bu you cannot add a modifier 25 to a 99211 for labs, this is forbidden, please read the article i found in Codepedia by using the "Look it Up"
THE USE OF 99211
There is no one complete source for the correct use of 99211. Each payor does its own thing. CPT® hasn’t been very helpful either. So some practices avoid using the code. That is a shame because just 5 encounters a week adds up to about $5,000.00 a year. Both NPPs and physicians may use the code. What follows is a compilation of the rules from CPT®, CPT® Assistant and CMS. Most payors have also agreed with the following list.
The face to face provider must be an employee, contractor or leased employee.
There must be direct supervision (i.e. a supervisor in the suite) for services.
The patient must be seen first by the Physician/Practitioner, so the service must be for an established patient.
There must be an order for the service and the ordering Physician/Practitioner identified.
The service must be some sort of evaluation and/or management and the actual evaluation or management must be documented to support the service
There must be a documented rationale for medical necessity.
There must be a date and clear identifier/signature of the face to face provider.
99211 is a -25 modifier eligible code so that other services can be billed when the use of the modifier is allowable.
99211 can be used for a medication refill IF the Physician/Practitioner is providing on-going management for the patient.
99211 may be used for drawing labs for immediate in-house protocol or order AND a management change happens due to the lab testing. In this case, you would not use the lab draw codes (eg. 36415)
99211 can be used for short patient teaching sessions that are medically necessary or reflect a medication change and are not part of an earlier visit with the Physician/Practitioner.
99211 can be used to report a flush of a port when no therapy is done.
99211 can be used for blood pressure check that are ordered and are medically necessary.
Under Medicare rules a 99211 can be used for PT and PTTs, if:
· face to face medication management is provided,
· there is documentation to establish a need for clinical evaluation and management of significant new symptoms or clearly demonstrating how the relevant lab information was used to modify therapy,
current medications are listed with notation of compliance,
an indication is documented showing the Physician/Practitioner’s evaluation of the labs and recommendation management recommendation, and
the clear identity and credentials of the staff and Physician/Practitioner.
FORBIDEN USAGE
CPT® specifically says: “Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT® code that merely approximates the service provided.” So do not use 99211 when another code described the service (eg. simple blood draw).
Using 99211 when no clinical need is documented.
Education that belongs to another service (eg. instructions on wound care for the biopsy the Physician/ practitioner.
Services normally bundled into another service (eg. vitals done by nurse in preparation for a visit with the Physician/Practitioner).
Using 99211 for a new patient visit.
Using 99211 for a nurse service not ordered by the Physician/Practitioner.
Using 99211 for a service provided over the telephone.
Printable Version
re: 99211 not being paid
If the patient was seen for only the venipuncture then it would not be appropriate to bill 99211, but if they were seen for any other issue then it would be appropriate. You have to determine if the documentation supports the use of the 25 modifier.
re: 99211 not being paid
i have tried with and without. started happening this year. Also, Medicare requires a 25 modifier nor for a 99211 or you will not be paid and they will say it is included with other services.
I learned that the hard way.
There is no clear picture anymore it seems. the insurance companies are profiting enormously and not paying out..
re: 99211 not being paid
Have you tried an appeal with documentation to support. Might be that carrier believes that many people use the 25 incorrectly to overide the rejection edit? If they see the notes support the addition of the 25, it might help.
re: 99211 not being paid
i have not appealed yet. i might look into it. all i want is a nurse visit paid with a venipuncture. simple.. no modifier needed.. and if they want one, sure i will add it.. just want to get paid!
re: 99211 not being paid
You cannot "Just have a nurse visit with a venipuncture" just as you cannot have a physician E&M visit with a pre-scheduled procedure. The venipuncture payment is for performing the routine venipuncture by whomever does it, including the doctor if it is a routine venipuncture. So the RN must perform another service that warrants a nurse visit. Now if the RN did a finger stick for a protime, you can charge for a 99211 if the results are reviewed with a provider and patient is questioned.
