Anesthesia Coding Alert

Watch out:  Use this code as a catch-all and prepare to see your reimbursement-and compliance-plummet

The long E/M descriptors in CPT should clear up any confusion about how to use these codes. Unfortunately, this is hardly the case when claims that may or may not require 99211 come across coders' desks.
 
When tackling proper 99211 use, you must dissect the major components of the CPT descriptor: Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.

Establish the Patient Status

Component 1: Established patient status. As you can see in the above descriptor, the patient must be "established."

According to CPT, "established" means that your physician (or another physician of the same specialty in a large group) has treated the patient within the past 3 years. "My understanding of 'established' patient does not depend on the place of service," says Pam Marshall, IS and contract specialist with Northern Colorado Professional Services in Ft. Collins. "Even if your doctor [the patient] in another practice group and didn't bill an initial visit, that patient is still established."

Double-Check for an E/M Service

Component 2: Someone - but not necessarily the physician - has provided an E/M service for the patient. "This clinical service is in addition to any injection or other service performed the same day," explains Cindy Parman, CPC, CPC-H, RCC, president of the AAPC National Advisory Board and principal of the consulting firm Coding Strategies in Dallas, Ga.

Example: A chronic pain patient is starting on a medication that requires blood level monitoring. She comes to the office and receives face-to-face counseling (such as interpretation of the test, discussion of dietary concerns and interactions with other medications) from qualified office staff. The staff also evaluates the patient and modifies the patient's treatment regimen. This visit could qualify for 99211.

Beat the Physician-Present Blues

Component 3: The physician is not always required to be present in the office and immediately available at the time the service is furnished. Your physician doesn't have to provide the actual service, but that doesn't mean services provided in his stead automatically merit 99211. Instead, be sure the case fits the criteria outlined here before submitting 99211 - and be familiar with the individual carrier's guidelines.

CPT interpretation: Although physicians can report 99211, CPT's intent with the code is to provide a way for you to report services performed by others in the practice (such as a nurse or other clinical staff member). According to CPT, the staff member may communicate with the physician about the patient, but direct intervention by the physician is not required.
 
Medicare interpretation: Medicare's requirements regarding this aspect of 99211 are a bit different. The physician's presence is not required at each 99211 service involving a Medicare patient, but he must at least be in the office suite when each service is provided. The physician must also initiate the service as part of a continuing plan of care. He should be an "ongoing participant" in this care, which to some carriers means he must see the patient at least every third visit.

Distinguish 99211 From Its Peers

Component 4: Code 99211 does not specify any required, key components. Other office visit codes (99201-99205 for new patients and 99212-99215 for established patients) require the provider to meet two or three key components (such as, problem focused history, problem focused examination and straightforward medical decision making). "99211 is a low-level code," says Parman, which helps explain why the key components aren't required. "The services are not considered to be complex, and they don't require the presence of a physician."

Example: A pain management patient comes in for a "return to work" release. If the physician talks with the patient and signs the release, you would code the visit with 99211. But the visit is much more involved if the physician talks with the patient, documents his current problems, examines the patient (takes his blood pressure and temperature), performs a brief exam of upper extremity strength and checks the patient's pain level. Code this visit with 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; straightforward medical decision making) instead of 99211.
 
Pitfall: "The biggest problem I see with 99211 is that it's used as a 'catch all' code for any visit made by the patient," Parman says. "This is not a code to use when the patient picks up a prescription or when the patient 'drops in' for something. The service must be medically necessary and ordered by the physician."

Dig Deeper for Less Obvious Criteria

Other criteria you must meet before reporting 99211 might not be included in the descriptor, but are equally important. These "hidden" criteria include: