EM Coding Alert

Question: Our provider saw a patient with GERD and started her on esomeprazole. The patient came back two weeks later, and the nurse evaluated her, taking blood pressure and other vitals. She also asked the patient if she had experienced side effects since she started on the medication. The patient reported that she vomited several times immediately upon starting the medication, but that she felt fine since then. The nurse recorded that information in the record and advised the patient to stay on the medication and to alert the practice if the vomiting or any other side effects return. Is this a good candidate for 99213?

South Carolina Subscriber

Answer: Since you stated that the nurse performed the visit, it sounds more like this describes an appropriate billing of 99211, assuming the nurse documents the visit thoroughly. A patient who has just started a new medication regimen usually reports to the provider by the latter’s order and is typically an established patient.

Although 99211 is often the best choice when a clinician performs a quick, medically necessary visit, it won’t always be paid. To avoid any payer queries, include this documentation on medication checkup E/Ms:

A record of patient’s blood pressure, if relevant, and other vital signs

A note indicating the clinical reason for checking blood pressure or other vital signs

A list of the patient’s current medications (include level of patient compliance, if possible) proof that the provider evaluated the clinical information the nurse obtained and made a management recommen­dation for the patient.