1. Many coders don't realize that they can use 99211 to report services provided by specified clinical employees other than the nurse, says Kathy Pride, CPC, CCS-P, HIM applications specialist with the San Rafael, Calif.-based QuadraMed.
Any qualified "auxiliary personnel" who are employees of the physician (such as medical assistants, licensed practical nurses, technicians and other aides) and are working under the physician's direct supervision can provide services to patients under the incident-to umbrella using 99211, Pride says. These clinicians can report 99211 as long as the patient visit meets the medical-necessity requirement for billing an E/M code, she says.
The physician must be present in the office space, and the auxiliary personnel must be qualified to perform the service. (For more information on auxiliary personnel, read Section 2050.1 of the Medicare Carriers Manual.)
Although CPT does not bar physicians from using 99211, they will use a higher-level E/M code in most cases because of the greater complexity of care they usually provide.
2. "If the service has an identifiable code, then you bill that code," Pride says.
For example, a patient comes to the office for a urinalysis as part of routine lab work scheduled a week before a regular checkup. In this case, you should use 81002 (Urinalysis, by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy) instead of 99211.
You cannot code 99211 for the time that the nurse or assistant spends with the patient unless another medically necessary service is provided in addition to the lab work, such as if the routine urinalysis is positive, indicating a urinary tract infection.
In this case, the nurse must then discuss the findings with the surgeon, who decides he doesn't need to see the patient before the exam the following week but will write a prescription for an antibiotic to be started in the interim.
The criteria for medical necessity have been met, and 99211 can be coded in addition to 81002, with diagnosis code 599.0 (Urinary tract infection, site not specified).
On the other hand, if the service provided to the patient by auxiliary personnel does not have an identifiable CPT code of its own, you may be able to use 99211. But providers must document medical necessity for the visit. Because 99211 does not have required elements of history, examination and decision-making, providers should establish the same medical necessity that CPT requires for all E/M codes, Pride says.
Coding consultants recommend that 99211 notes include:
Vital signs
The patient's chief complaint, if appropriate
Evaluation of the patient's medical condition
Description of the service provided
Name of the attending surgeon
Questions the patient asks and responses given
Notes on follow-up care
3. No, you would not bill 99211 if the physician phones in orders or care-plan changes from an off-site location, such as the hospital. Code 99211 services must be an integral part of a patient's care plan but incident-to the physician's care. Although the patient need not have face-to-face contact with the physician to bill 99211, the physician must be available in the office suite.
4. "Did the doctor write out the prescription and leave it at the front desk for the patient to pick up?" Pride asks. If the answer is yes, and the patient simply picked up the prescription and left, the refill cannot be billed as 99211.
If there is a medical reason for the nurse or other office personnel to evaluate the patient when he comes in to pick up the prescription, however, use 99211. For example, you would bill 99211 if the physician recently changed blood-pressure medications and wants the nurse to evaluate the effect on the patient before the physician gives him a three-month prescription renewal of the medicine.
5. Coders often disagree about whether to use 99211 or the 90782-90799 series (Therapeutic, prophylactic or diagnostic injections) for shots given in the office. Medicare specifically says in 15502 (D) of the
Medicare Carriers Manual not to use 99211 for injections, warning that the code "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 the surgeon or his or her staff provides an E/M service along with an injection, Medicare says it will cover the E/M service but will bundle the injection administration (90782-90799) into the appropriate E/M code. In both cases, use a J code to indicate the drug administered.
