# 99211 documentation requirements



## kdricklefsbarrett@pchsweb.org (May 11, 2015)

I have a question about documentation requirements for 99211 now that the service is under the "general supervision" of a physician, not the "direct supervision" of the physician. (based on changes effective 1/1/2015)

Does the physician still need to sign off on the visit/notes - assuming the nurse visit followed the established patient plan?

Thank you for your help.
Kim


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## CatchTheWind (May 15, 2015)

Where did you see these 1/1/15 changes?  I was not aware of them. 

There is/was no physician signature requirement when the service is performed under direct supervision (unless under your carrier or state law).


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## Leenahz (May 18, 2015)

I'm interested to know where these changes were seen too...

Lena


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## mitchellde (May 18, 2015)

The requirements for the 99211 have not changed that I can find.  A nurse must still have direct physician supervision.  The PA and NP will be dependent on state law.


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## BenCrocker (May 18, 2015)

Yes my CPT and my Procedural Coding Expert (both 2015) have no requirements of a physician needing to be present. I think someone is combining 99211 and the "incident to" rules.


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## mitchellde (May 18, 2015)

I think the problem may be exactly what Ben stated.  It is a common misconception that a 99211 is a nurse visit.  It is not it is a physician level.  It is the level of service the physician charges when other qualified staff are fulfilling orders from a previous visit or it is a low level physician service when the three key criteria are not documented as performed.  For a nurse only encounter to be charged as a 99211 you must meet the criteria of incident to.  While it is a Medicare definition for incident to most every carrier applies it the same as medicare. Also as an RN/LPN in a physician office, the physician or NP must be in the office while the patient is present.


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## kdricklefsbarrett@pchsweb.org (May 20, 2015)

Thank you everyone for your input!

Yes, I am specifically asking about 99211 when used as Incident To Billing. As of 1/1/15 the Incident To Billing guidelines no longer require the MD to be on premises when the service is provided, but requires that the patient is under the general supervision of the MD.

As long as the nurse/pharmacist follows the MD's established patient plan, does the MD need to sign off on the visit still?

Thank you.


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## mitchellde (May 20, 2015)

kdricklefsbarrett@pchsweb.org said:


> Thank you everyone for your input!
> 
> Yes, I am specifically asking about 99211 when used as Incident To Billing. As of 1/1/15 the Incident To Billing guidelines no longer require the MD to be on premises when the service is provided, but requires that the patient is under the general supervision of the MD.
> 
> ...


The incident to rules have not been rewritten.  The provider must be on the office at the time of the encounter to use his NPI on the claim as the rendering provider.  Can you please indicate where you are getting this information?


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## teresabug (May 20, 2015)

Deborah is correct. Incident to requires the physician to be physically present in the actual office suite. Go on wps.medicare.com and select your MAC and search 99211 for clarification on guidelines. Incident to billing and CPT 99211 are not the same.


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