Gastroenterology Coding Alert

Experts say that if you can report this code, you should

Do you think you-re using 99211 appropriately? Find out by learning three criteria and then taking a three-scenario challenge.

Heads up: Although you probably refer to 99211 as the -nurse's code,- your gastroenterologist and other personnel should report it if an E/M visit doesn't meet the documentation requirements of the higher-level established patient E/M codes (99212-99215).

Our coding experts recommend that you report 99211 (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) if the service meets these three principles:

1. Staff Performs an Actual E/M Visit

To report 99211, a practitioner must perform an E/M service. In other words, don't use 99211 simply to get any simple service paid.

Example: A nurse speaks to a patient on the phone and agrees to obtain a prescription refill for her. The patient comes to the practice an hour later, and the nurse hands her the prescription through the reception window.

Solution: Because the nurse did not evaluate the patient and no medical necessity required that she meet with her, you should not report an office visit. If the nurse couldn't renew the patient's prescription without evaluating her, however, she should have documented the medical necessity to support billing 99211.
 
Anytime you report 99211, the nurse should document the reason for the visit, a brief history of the patient's illness, any exam processes such as weight or temperature, and a brief assessment.

What to look for: Check the documentation for notes such as -Wound has healed well,- -Blood pressure is serve as proof that the practitioner met with the patient
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-I look for the patient's vitals, where the practitioner made the injection, and the drug specifics,- says Cindy Foley, billing manager for Samuel S. Badalian, MD, PC and Nesim Contente, MD, PC in Syracuse, N.Y.

Also, make sure you have the date of service, the reason for the visit, proof that the nurse performed the service per the physician's order, and the nurse's signature, says Loretta Sacco, CPC, insurance/coding coordinator for IHA of Ann Arbor PC in Michigan.

Did you know? Any qualified personnel who are employees of the gastroenterologist can report 99211, including medical assistants, licensed practical nurses, technicians and other aides working under the physician's direct supervision.

2. The Service Is Medically Necessary

If you think all nurse visits warrant using 99211, you could land in compliance hot water.

Example: A patient comes into the office for a blood pressure (BP) check because she recently had a high BP reading. Today's reading is normal. 

Solution: -If the patient came in for a blood pressure check and did not see the doctor, we would bill 99211 for the nurse,- says Mary Vollmer, coder at Allied GI Associates in Haddon Heights, N.J.

Good advice: -You should certainly use this code when it's appropriate over waiving the charge, which I-ve seen happen before,- Foley says. -Regardless of why the patient is in the office, she's here to use our expertise and services, and that's a legitimate charge we coders should bill. Sometimes the reimbursement is little more than the copay, but that's not the point. We need to charge for our time, every time.-

3. The Patient Is an Established Patient

The new patient E/M codes do not offer an equivalent to 99211. Registered nurses cannot report 99201, the lowest-level new patient office visit code, because physicians must see new patients, or established patients who have new problems, before you can report 99211. -It's the rule,- Foley says.

Part of the specifications for using 99211 is that -there is an established treatment plan and medical necessity for the follow-up, and it's documented in the patient's medical record,- Sacco says.

Take This 99211 Challenge

Think you-ve learned how to use 99211? Check out three common gastroenterologist scenarios and determine whether you should report this code under these circumstances:

Scenario 1: A patient presents for a blood draw.

What to do: If the patient comes in only for a blood draw, you should charge 36415 (Collection of venous blood by venipuncture) instead of 99211. But you may report 99211 if the nurse takes the patient's history or documents a chief complaint. Some carriers, however, may bundle the E/M service with the venipuncture code or vice versa.

Scenario 2: Your gastroenterologist provides a minor amount of E/M service and then performs a flexible sigmoidoscopy (45330, Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

What to do: You should not use 99211. -You should not bill an E/M code if the visit was part of the flexible sigmoidoscopy,- Vollmer says. In fact, if you do report this code in addition to 45330, your payer might deny the whole procedural service.

Scenario 3: An established patient with anemia reports to the office for a monthly B-12 injection. Noting the gastroenterologist's request in the patient file, the nurse checks with the patient about her reactions to the shots and discusses scaling back to B-12 injections quarterly. The nurse then injects the patient with B-12, and the entire visit takes six minutes.

What to do: Usually, the administration code (90772, Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) covers the nurse's work, but because the nurse provided a separate E/M service, you can also report 99211 with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).