# Dip UA and 99211?



## jifnif (Dec 29, 2009)

If the pt sees the nurse for a dip UA and gets the diagnosis and the dr writes a script and is counseled by the dr can we charge a 99211?  I say yes but our drs want to see it in writing and the only place I can find legitimate support is in reference to immunizations/pediatrics.  Does anyone have a better or other source?


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## mitchellde (Dec 29, 2009)

you may not charge a 99211 as a nurse visit in this circumstane.  The physician must have already examined the patient in a prior encounter and have the plan docuemnted for a return visit and must be present in the office.  SO the patient has not been examined by the physician and ordered a follow up encounter.  Ig the physician sees the patient in a face to face then he must document his own exam and can bill then what ever level his documentation supports.  Signing off on the nurse documentation is not sufficient to bill any level.  You may not bill a 99211 to administer injections either.


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## jifnif (Dec 29, 2009)

*Confused*

I am confused as why it cannot be billed as a 99211.  The nurse saw the pt and did the dip and diagnosed and dr wrote the rx.  why wouldnt this count as incident-to?


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## LLovett (Dec 29, 2009)

You can't be incident to on a new problem. 

If the doctor sees the patient they should have a note and you should at least have a 99212.

I agree with Debra on this one, in fact I just had to remove a 99211 from our billing system for the same scenario. 


Laura, CPC, CEMC


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## mitchellde (Dec 29, 2009)

jifnif said:


> I am confused as why it cannot be billed as a 99211.  The nurse saw the pt and did the dip and diagnosed and dr wrote the rx.  why wouldnt this count as incident-to?



Also a nursing credential does not give a nurse the ability to render a dx to a patient .  That can be done only by a physician.


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## jifnif (Dec 29, 2009)

Okay, I am understanding.  I guess my confusion comes from the trailblazers site that states the criteria for billing a 99211.  I don't see where it says the pt has to be seen prior to the visit.  
from trailblazers/cms:
Code 99211 requires a face-to-face patient encounter; however, when billed as an “incident to” service, the physician's service may be performed by ancillary staff and billed as if the physician personally performed the service. For such instances, all billing and payment requirements for “incident to” services must be met.
As with all services billed to Medicare, code 99211 services must be reasonable and necessary for the diagnosis or treatment of an illness or injury. Unlike the other E/M CPT codes, the CPT book does not specify completion of particular levels of work for code 99211 in terms of key components or contributory factors. Also, unlike the other E/M codes, CMS did not provide documentation requirements for code 99211 in the “E/M Documentation Guidelines.”
CPT code 99211 describes a service that is a face-to-face encounter with a patient consisting of elements of both evaluation and management. The evaluation portion of code 99211 is substantiated when the record includes documentation of a clinically relevant and necessary exchange of information (historical information and/or physical data) between the provider and the patient. The management portion of code 99211 is substantiated when the record demonstrates influence by the service of patient care (medical decision-making, provision of patient education, etc.). Documentation of all code 99211 services must be legible and include the identity and credentials of the individual who provided the service.
forgive me, i am new to family practice.


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## Walker22 (Dec 29, 2009)

The reason a nurse visit can't be charged in this case is not because it doesn't meet the criteria for 99211, but rather because it doesn't meet the criteria for "incident-to".


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## mitchellde (Dec 29, 2009)

Walker 22 is correct.  In your statement from trailblazers you state"For such instances, all billing and payment requirements for “incident to” services must be met."  Incident to requirements state the physician must first examine the patient for the same dx and have a plan of care that includes this visit as a follow up.  And the physician must be present in the office.  That is per Medicare section 2050.


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## mshay134 (Jan 5, 2010)

An example of 99211 being used correctly is when the provider sees a patient with htn and makes med change.  The patient is told to return for bp check by the nurse.  Pt returns, nurse takes bp and reviews with provider.  Pt is instructed to either continue with same meds or med change is made.  This would be correctly coded as 99211.

Meg, CPC


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## jifnif (Feb 12, 2010)

*Still having office issues!*

Sorry to bring up this dead horse again, but.....a dr from our office insists on billing for this scenario due to an article from aafp: http://www.aafp.org/fpm/2004/0600/p32.html

The article states as an example:  An established pt comes in c/o urinary burning and frequency.  Nurse takes history, reviews med record, discusses situatin w/ dr and orders ua.  nurse presents findings to dr who writes an rx for an antiobiotic.  nurse gives instructions to pt and documents encounter.  per the article this is okay to bill the 99211.  

From what everyone has told me that is not appropriate b/c it is a new problem.  Well, I have trouble with the drs to begin with b/c they don't want to listen to a coder.  Then I tell them they can not bill for the 99211 in the above situation and now they find the exact situation on aafp and say they are going to bill for it.  

Sorry, but who is correct here.  I am the only coder in a billing company for 12 practices and have no voice.  I give up the information and they fight it anyway.  If it is not medicare, does this mean they can bill for it?  I really am so frustrated so please bare w/ me.  Thanks to everyone!


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## cheermom68 (Feb 12, 2010)

*incident to*

Most payors follow "incident to" guidelines, however some do not.  You would have to check with the individual payor to determine whether they follow the guidelines.  The article you refered to is probably not addressing  "incident to" but just addressing the CPT guidelines for the billing of 99211.
So... according to CPT guidelines it would be appropriate to bill a 99211 however depending on the payor it may not be appropriate because it does not follow the "incident to" guidelines.  You can access the "incident to" guidelines on the CMS website.


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## dballard2004 (Feb 12, 2010)

Here is what the article says:

An established patient comes to the office with complaints of urinary burning and frequency. The nurse takes a focused history, reviews the medical record, discusses the situation with the physician and orders a urinalysis. The nurse then presents the findings to the physician, who writes a prescription for an antibiotic. The nurse communicates the instructions to the patient and documents the encounter in the medical record. In this example, 99211 and the appropriate laboratory code for the urinalysis should be reported because the E/M service is distinct from the lab service and appropriate for the evaluation of the patient’s complaint.

I would agree that 99211 would be appropriate here.  There is physician interaction.  The physician ordered the UA, reviewed the results, and ordered an antibiotic.  The RN is carrying out the provider's order here, so 99211 can be used here.  The physician is also onsite and the RN is carrying out the plan of care here, so aren't you meeeting the incident to requirements?  I believe so.


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## Anna Weaver (Feb 12, 2010)

I believe this is one of those gray areas in a coder's black and white world. My understanding of the first post was the Dr. did not see the patient, did not order the UA, did not discuss anything until after the fact, then gave a script based on results from the nurse. This then would not meet the requirements for incident to. If the Dr. was in fact the one to order the UA, discuss it with the nurse, then prescribe, I agree it could be billed as incident to. There's a difference, subtle, but different in the scenarios listed.


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## LLovett (Feb 12, 2010)

I think cheermom hit the nail on the head. Depends on the carrier. The original question was in regards to a medicare patient (Trailblazer). This scenario does not meet CMS requirements for incident to. 

The article posted is more in regards to what supports a 99211, not incident to guidelines.

Laura, CPC, CPMA, CEMC


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## jifnif (Feb 12, 2010)

Thanks to everyone.  This is huge because the office wants to bill all ua's at this level.  I would think the office should take a stand to follow cms guidelines or not to and if we get paid then great and if not, okay too.


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## mitchellde (Feb 12, 2010)

Well geeze!  I wish these organizations would not release these types of articles without having them proofed by an authority first.  But the article is INCORRECT, and there is is no nice way to say that.  If your physician would like I would be more than happy to write a rebuttal to this and send to the organization just give me the address to where I need to send it.


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## dballard2004 (Feb 12, 2010)

Would someone please explain to me how this article is incorrect?  Based on what I read, the scenario meets the criteria for 99211.  What am I missing here?


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## LLovett (Feb 12, 2010)

It looks like that article was published in 2004 and sites things from 2000.

I agree with Debra, this article is incorrect in saying Medicare will pay for these services as 2 of the 4 are new problems and don't meet incident to requirements. It tells you the type of services that can support a 99211 but it is also saying that Medicare will pay for these. She clearly contradicts herself in the article. 

"Medicare's requirements on this point are slightly different: While the physician's presence is not required at each 99211 service involving a Medicare patient, 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. "

Then goes on to give examples of new problems, like the one previously posted. 

That is why this service does not meet incident to guidelines, the physician did not see the patient for it first therefore they are not following the physicians treatment plan.

Laura, CPC, CPMA, CEMC


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## dballard2004 (Feb 12, 2010)

So if a patient comes into the clinic with an order from an outside provider (not our doc) for a BP check, this is not a 99211 because our provider did not see them first, or does this only apply to Medicare?


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## jifnif (Feb 12, 2010)

It is my understanding that this is Medicare specific and not CPT specific.  I have found in this journey though that it is payor specific!  I am encouraging this family practice to stick to Medicare guidelines.  In saying that, I believe that if you are going to follow Medicare guidelines and you do a BP check, your note would have to reference the physician that first saw the patient for that particular problem and a date has to be referenced as well.  Not sure if it matters if the provider is from another practice or not.  Sorry.  Not to mention for our family practice....this means a copay for the patients.  I am not so sure I would pay a copay for a UA or a BP check.  Doesn't seem right. Someone can correct me if I am wrong, this whole situation just fries my brain!!!


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## mitchellde (Feb 12, 2010)

The catch is that your nurse is not employed by the other physician and therefore may not follow the orders from that physician.  She may follow the orders given by her physician only.


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## dballard2004 (Feb 15, 2010)

Thanks so much!


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