99211 What Are The Rules???

As I was putting together a presentation on E/M documentation, it occurred to me that many people have a problem with correctly using 99211.  Many coders and physicians seem to believe that if a patient comes in for a service (blood work, shot, pressure check, etc) and is not seen by the physician, they can automatically bill a 99211.  Not necessarily true.

The guidelines for most evaluation and management (E/M) codes are very precise. However, the one exception is the established patient encounter code, 99211. CPT defines this code 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."  It further states that the presenting problems are usually minimal, and typically five minutes is spent performing or supervising these services. Yet most coders still struggle with when to report this code.

Appropriately reporting 99211 services can improve documentation in a practice. Staff members who are familiar with billing guidelines tend to pay increased attention to documentation, which, in turn, can result in a more useful medical record for all providers involved in the care of the patient.  Reporting 99211 correctly could bring additional revenue into your practice. Most practices already provide a number of 99211 services, but fail to capture those charges or are billing it incorrectly.

The following guidelines can help you decide whether a service qualifies for 99211:
The patient must be established. According to CPT, an established patient is one who has received professional services from the physician or another physician of the same specialty in the same group practice within the past three years. Code 99211 cannot be reported for services provided to patients who are new to the physician.

The provider-patient encounter must be face-to-face. For this reason, telephone calls with patients do not meet the requirements for reporting 99211.
An E/M service must be provided. Generally, this means that the patient's history is reviewed, a limited physical assessment is performed, or some degree of decision making occurs. If a clinical need cannot be substantiated, 99211 should not be reported. For example, 99211 would not be appropriate when a patient comes into the office just to pick up a routine prescription.

Also, if another CPT code more accurately describes the service being provided, that code should be reported instead of 99211. For example, if a physician instructs a patient to come to the office to have blood drawn for routine labs, the nurse or lab technician should report CPT code 36415 (routine venipuncture) instead of 99211 since an E/M service was not required.  Also, just because the nurse or MA takes vitals before doing a venipuncture or giving a shot does not make it an E/M service.

The service must be separate from other services performed on the same day. Services that are considered part of another E/M service provided on the same day should not be reported with code 99211. For example, if a nurse provides instructions following a physician's minor procedure or takes a patient's vital signs prior to an encounter with the physician, 99211 should not be reported for these activities because they are considered part of the E/M service already being provided by the physician.

The presence of a physician is not always required. Although physicians can report 99211, the intent with the code is to provide a mechanism to report services rendered by other individuals in the practice (such as a nurse or other clinical staff member). According to CPT, the staff member may communicate with the physician, but direct intervention by the physician is not required.

Medicare's requirements are slightly different.  The physician must have initiated the service as part of a continuing plan of care in which he or she will be an ongoing participant.  In addition, the physician must at least be in the office suite when each service is provided. The reason for this difference is that Medicare considers these services to be an integral, although "incidental," part of the physician's professional service. According to Medicare and most third-party payers, incidental services should generally be reported under the name and billing number of the physician or other professional in the office suite when the service is provided. Note that the services can also be billed "incident-to" other health professionals, such as physician assistants or nurse practitioners.
No key components are required. Unlike other office visit E/M codes - such as 99212, which requires at least two of three key components (problem-focused history, problem-focused examination, and straightforward medical decision making) - the documentation of a 99211 visit does not have any specific key-component requirements. The note just needs to include sufficient information to support the reason for the encounter and any relevant history, physical assessment, and plan of care. The date of service and the identity of the person providing the care should be noted along with any interaction with the supervising physician.

Be cautious about establishing a practice of billing an E/M service with every staff encounter.  Most services provided are more appropriately reported with a CPT code other than 99211.  Not every encounter has a clinical indication that supports a separate visit code.  I hope you will use these guidelines to determine the appropriate uses of 99211 for your office. Staying knowledgeable about these coding practices can improve your practice's reimbursement and reduce potential audit liability.

Marge McQuade, CMSCS, CMM, CHCI has over 35 years experience in the medical field as an office manager, coder and educator.  At present, Marge is the Director of Education for PAHCS (Professional Association of Healthcare Coding Specialists).  She is an active member of PAHCOM and AAPC. Marge is a past Advisory Board member for several HCPro publications and currently is a contributing editor for BC Advantage.  Contact her at margepahcs@gmail.com.