Internal Medicine Coding Alert

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. Because 99211 does not have required elements of history, examination and decision-making, many physician offices are unsure when and how to use the code. The key is to establish the same medical necessity that is required for all E/M codes. "Make sure you document what service was performed and the medical necessity for it," Pride says.

"Here are three of the most common scenarios where coders question if 99211 is the proper code and some expert advice on when to use it."

If a patient comes in to have her blood pressure checked because the doctor said she should have it done 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" to patients, she says.

However, if there is medical necessity for the blood-pressure check, it will meet the criteria for 99211, Brink says. For example, the doctor examines a 65-year-old female patient whose blood pressure is high and decides to try a new medication. The physician 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." His notes create medical necessity for 99211 to be coded when the patient returns.

Many offices believe they can create medical necessity by having the nurse ask how the patient is feeling at a routine blood-pressure check but that's not the case, Brink says. If, however, the nurse asks and the patient responds, "I've been dizzy, and I think it's because of this new medicine," then medical necessity exists for coding 99211 or perhaps even a higher-level visit with the doctor, depending on what the nurse's initial assessment shows, Brink says.

Another frequent question is whether offices can code 99211 for a prescription refill.

"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.

However, 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, use 99211. For example, the doctor recently changed blood-pressure medications and wants the nurse to evaluate the effect on the patient before giving him a three-month prescription of the medicine.

Coders often disagree about whether to use 99211 or the 90782-90799 series (Therapeutic, prophylactic or diagnostic injections) for shots given in the office. Although CPT lists a routine B-12 shot for pernicious anemia among its examples of correct 99211 coding, 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 an E/M service is provided along with an injection, Medicare says, the E/M service is covered but the administration of the injection (90782-90799) is bundled into the E/M. In both cases, use a J code to indicate the drug administered.

To code 99211 for an injection, you have to do more than administer the shot, Pride says. For example, a 75-year-old female patient receives her B-12 shot for pernicious anemia then says she feels dizzy. The nurse evaluates her and monitors her for 20 minutes before the woman feels better and leaves.

Code this visit with 99211 and J3420 (Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg), along with diagnosis codes of 281.0 (Pernicious anemia) and 780.4 (Dizziness and giddiness).