General Surgery Coding Alert

Question: I’ve been told I should use 99211 for a nurse’s time with a new patient in our practice. Is that correct?

South Carolina Subscriber

Answer: No, you should not 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 or other qualified health care professional) for an office visit performed entirely by a nurse for a new patient.

First, the code descriptor specifies that the code is for an established patient. You should report a new patient visit with a code such as 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making …), at a minimum.

New patient encounters typically require the expertise of a physician or other eligible qualified healthcare professional (QHP) because neither the patient, nor their condition(s) are known. Reimbursement is typically higher for a new patient visit at the same level (e.g., 99202 versus 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.)) because of the extra work and time involved in gathering information and determining diagnose(s).

Remember: Medicare regards certain services provided by someone other than a physician or QHP as incident-to the physician or QHP, which you cannot report for a new patient. One of the many requirements for incident-to reporting is that there must be a previously established course of treatment in place, which of course wouldn’t be the case for a new patient.