Re-evaluate Use of 99211 to Reduce Medicare Scrutiny
Published on Thu Jun 01, 2000
Gastroenterology practices should avoid billing for a significant number of level-one established patient office visits (99211). Many times what is reported with code 99211 should be billed as a higher-level evaluation and management (E/M) service or not be billed at all.
Code 99211 should rarely be used by gastroenterologists, if at all, says Tammy Chidester, CPC, billing supervisor at Upshur Medical Management Services, a multi-specialty practice in Buckhannon, W.Va. Any type of medical decision-making, history or exam done by the gastroenterologist probably warrants a higher-level E/M code.
CPT defines 99211 as 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.
Missing from that definition are the history, examination and medical decision-making components that are required of most other E/M codes. Because the CPT states that the presence of a physician is not necessary, the code often is used to bill services by a non-physician provider, such as a registered nurse.
Injections Dont Always Qualify as E/M Service
One of the most common services reported with this code is the administration of an injection by a nurse or other non-physician provider. Although code 90782 (therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) also can be used to report injections, reimbursement is higher for 99211. The CPT seems to support the use of 99211 for injections when it cites an office visit for a 50-year-old female, established patient, with pernicious anemia for a weekly B12 injection as a clinical gastroenterological example of the code in its Appendix D.
Medicare disagrees. The Medicare Carriers Manual section 15502(D) states, CPT code 99211 cannot be used to report a visit solely for the purpose of receiving an injection which meets the definition of CPT codes 90782, 90783, 90784, or 90788.
If an additional medically necessary E/M service, such as a blood pressure check, also is performed at the time an injection is administered, Chidester believes that Medicare would then cover the service as an office visit. If just an injection is being given, however, she feels that gastroenterology practices should bill only the injection code.
Patient Education by Nurse Is Appropriate Use
Patient education by a nurse is another appropriate use for 99211, when there is documentation containing details regarding the services provided by the nurse in the patients medical record. For example, if a nurse teaches a patient with hepatitis how to self-inject interferon, Chidester feels this is an appropriate use of the code though she believes in practice it will be rare that only the nurse will see [...]
