Gastroenterology Coding Alert

Question: What are the minimum documentation requirements needed to bill 99211? What has to happen in a 99211 encounter in order for me to bill it?

Arizona Subscriber

Answer: Part of the confusion surrounding 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.) lies in the fact that, unlike all the other office and outpatient evaluation and management (E/M) codes, 99211 has no medical decision making (MDM) level requirements. The confusion over the code may also increase after Jan. 1, 2022, when the words “usually, the presenting problem(s) are minimal” will no longer be a part of the code descriptor for 99211, suggesting the patient need not have any presenting problems in order for you to bill 99211.

In fact, even after the change, you will still not be able to use the code to document a service that does not have an E/M component or use 99211 if the only service provided at the encounter is a service that has its own CPT^® code.

Services performed on their own, and that have their own CPT^® code (such as routine venipuncture and immunizations or other injections) cannot be billed using 99211. Additionally, routine services such as blood pressure checks or prescription refills (providing no change in medication or dosage occurs) cannot be billed using 99211.

Remember: If performed along with a separate and significant E/M service, including 99211, any service that can be documented with a CPT^® code can be billed as well providing modifiers 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) or 57 (Decision for surgery) are appended to the E/M, depending on encounter specifics.

If you have an order from your gastroenterologist that the patient must be evaluated and that the service is medically necessary to manage a specific patient condition, or chief complaint, then you can justify billing 99211.

A note would typically be expected to include some patient vital signs and some clinical observations related to the condition being treated. For example, a 99211 might be justified for a hypertension follow-up by a medical assistant for a patient started on new medication, asked about side effects, recording vital signs and noting presence or absence of edema — in effect, following a standard protocol set by the physician. However, even a brief check-in with the physician in person would raise the level to 99212.