General Surgery Coding Alert

Do patients come into the office for blood pressure checks or other brief E/M services on days they don't see the surgeon? If so, your general surgery practice can bill Medicare and some private insurers for many of these "nurse-only" visits (99211) if your nursing and nonphysician practitioner (NPP) staff know how to provide and document the services.

Remember, 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) only when established patients receive services from nursing staff and NPPs, including such personnel as physician assistants (PA), nurse practitioners, and certified nurse specialists (CNS), as part of a physician's plan of care for a health problem.

Although physicians can bill 99211, typically the lowest level E/M code a physician will report for an established patient is 99212 because it requires at least two of the three E/M components (history, exam and medical decision-making).

Code 99211 services may be an integral part of a patient's care plan but "incident-to" the physician's care, according to Mary Mulholland, CPC, RN, reimbursement analyst at the University of Pennsylvania's department of medicine in Philadelphia. To bill Medicare for 99211, there must be a medical necessity for providing the E/M service and the physician must be present in the office suite in case the patient needs to be seen. Private insurers may not have that requirement, however.

You can bill 99211 for blood pressure monitoring for hypertensive patients under a surgeon's plan of care, but only if there is established medical necessity for the blood pressure check, says Catherine Brink, CMM, CPC, president of Health Care Resource Management Inc., in Spring Lake, N.J.

"If a patient comes in to have her blood pressure checked by the nurse because the physician documented that she should have it monitored every two weeks, the visit can't be billed," Brink says. Providing a blood pressure check in the absence of other problems should be considered "a good-will gesture" and does not constitute medical necessity for billing, she says.

If there is medical necessity for blood pressure monitoring, however, it will meet the criteria for 99211, Brink says. For example, the surgeon examines a 65-year-old female patient during a preoperative exam and finds that her blood pressure is high. He decides to put her on medication to correct the problem. He notes in the chart that "the patient should return in two weeks to see the nurse for a blood pressure check, an evaluation of how the new BP medicine is working, and follow-up." The surgeon's notes indicate medical necessity for reporting 99211 when the patient returns, she adds.

Keep in mind that many private insurers don't have an official policy on paying for nurse-only visits. When asked, third-party (nongovernment) payers often suggest that the practice bill such services under the physician's name, coding experts say.

To report 99211, NPPs must document the services they provide to meet the standard of care and ensure medical records will pass a Medicare audit.

Code 99211 differs from the other office visit codes in that it does not require the three E/M components needed for other office visit codes. So, to prove medical necessity for levels of medical decision-making, NPPs in surgery practices still need to provide as much information about the encounter as possible to ensure reimbursement.

"You have to record more than just vital signs," says Judy Richardson, MSA, RN, CCS, senior consultant at Hill & Associates in Wilmington, N.C. "The note should include a mini-assessment, a brief description of the service provided, what was discussed, questions the patient asked, the outcome, and follow-up."

For example, if a provider sees a Coumadin patient who is being monitored with lab tests, he or she should document an assessment of whether the patient has any signs of bruising or bleeding, Richardson says. Once the surgeon sees the patient based on the NPP's findings, you should report the visit as a physician visit, which replaces the nurse-only visit. Even so, the nurse would still document his or her own patient evaluation.

General surgery practices should require all staff providing incident-to services to document in the progress note the name of the physician on-site for supervision, Brink says.