Cardiology Coding Alert

Question: Our practice is starting a Coumadin clinic. In addition to charging for a finger stick and prothrombin time (PT), the clinic manager has indicated that every patient visit will be coded 99211 under incident-to guidelines (even though they are not all Medicare beneficiaries). Although not every patient will need counseling or changes to his or her medication, vital signs will be taken for each patient and PT results will be documented. Does this support coding 99211?

Texas Subscriber

Answer: Established patient code 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) requires minimal documentation to justify its use. If, for example, a nurse performs (and documents) even a nominal level of evaluation and management, 99211 can be coded. But if the nurse only performs a service that has its own code, 99211 should not be used, says Cynthia Swanson, RN, CCS-P, a cardiology coding and reimbursement specialist with Seim, Johnson, Sestak & Quist, LLP, in Omaha, Neb. It is incorrect to bill 99211 every time a patient sees a nurse, she warns. You need to document enough to indicate a visit took place. Swanson notes that this could include taking the patients vital signs or answering questions.

For Coumadin clinic visits, 99211 should not be coded if the nurse only draws blood. Instead, the Coumadin draw should be coded 36415 (routine venipuncture or finger/heel/ ear stick for collection of specimen[s]) for third-party payers. Medicare carriers prefer HCPCS code G0001 (routine venipuncture for collection of specimen[s]). If the clinic owns the equipment, 85610 (prothrombin time) may also be billed.

It is not difficult to meet (and document) the requirements for performing 99211. When patients are seen at a Coumadin clinic a nurse routinely takes vital signs, asks about changes in diet or easy bruising of skin and may offer counseling. Often, changes are also made to the patients medication or how he or she is monitored. If any of these services are documented, 99211 can be coded, says Martha Gerant, CPC, a coder with Cardiology Services, an 11-physician practice in Shawnee Mission, Kan.

Gerant notes, however, that taking the patients vital signs during each visit may not be warranted. The best guideline to follow is this: If the nurse advises or monitors the patient, 99211 should be charged. If the patient is there for a few minutes, no vital signs are taken and the nurse does only lab work, charge only the specimen draw.

Note: Although 99211 does not reimbursement very highly (0.69 relative value units, or about $20), it is on HCFAs audit watch list because it is so widely abused. Many carriers now require providers to list three vital signs to prove the visit took place.