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Internal Medicine Coding Alert

Lower-Level E/M Codes May Generate Higher Revenue

Published on Thu Nov 01, 2001

Proper use of low-level office visit codes (99201, office or other outpatient visit for the evaluation and management of a new patient, which requires a problem focused history and examination and straightforward medical decision making; and 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) can provide an important stream of revenue for internal medicine practices. However, many practices misuse these codes and may incur penalties.

99211 Reported More Frequently

Established patient code 99211 is assigned more frequently than the corresponding new patient code 99201 and is often referred to as a "nurse visit." This basic level of service does not require the presence of a physician, nurse practitioner (NP) or physician assistant (PA) and is usually provided by a registered nurse, licensed practical nurse or certified medical assistant. Linda Jackson, CCS, CPC, Medicare consultant at Iowa Veterans Home, a residential facility that provides professionally managed healthcare for aging veterans in Marshall Town, Iowa, cites the following examples of when 99211 may be assigned:
 
  • patient comes in to have sutures removed
  • patient returns for a simple ear lavage performed by a nurse
  • patient is seen for a blood pressure check
  • patient comes in to access diabetic information
  • patient comes in for immunization results reading.

    • Unlike other office visit E/M codes, 99211 has no documentation requirements for history, physical exam or medical decision-making, but certain criteria must be met. "The nurse must meet with the patient and document the visit thoroughly. This includes the date, reason for the patient's visit, findings of the visit, the service provided per the doctor's order and the nurse's signature," Jackson explains.
     
    Most 99211 visits are billed as "incident to" services and must follow the appropriate guidelines under two conditions. "First, the physician or nonphysician practitioner (NPP) must have originally established a treatment plan," Jackson says. Second, the physician or NPP must directly supervise the nurse. Although they need not be in the exam room, they must be physically present in the office or clinic. "Availability by phone does not meet the requirement," Jackson adds.
     
    A low-level visit not billed as incident to occurs when an established patient comes in for a nurse's signature on a return-to-work certificate. The patient then leaves without seeing a physician. As long as the nurse documents this information and the service provided, 99211 would not be billed as an incident to service.

    When Not To Report 99211

    Excessive reporting of 99211 caused Medicare fraud investigations, and practices must ensure they use the code correctly. Jackson stresses the importance of educating coders on 99211 guidelines. "It is quite easy to assign 99211 for services that just are not covered," she says. Examples include:
     
  • Telephone calls. Frequently, practices will be in contact with patients by phone to discuss prescription refills, test results or diagnoses, or to explain specific aspects of care. These, however, should be billed with 99371-99373 (case management services, telephone calls).
     
  • Non-face-to-face time spent reviewing records and tests, arranging for further services or communicating with other professionals through written reports or telephone contacts.
     
  • Completion of forms like home-health or durableequipment certification forms.
     
  • When the patient has been instructed to leave a laboratory specimen at the office for a follow-up on a previous complaint or diagnosis and no other service is provided at that time.
     
  • Services to homebound patients.

    • Jackson also points out that 99211 should not be reported when a patient is seen in the office simply for an injection or to draw blood. The services provided by the nurse or medical technician are included in the procedure charge, i.e., 95115, professional services for allergen immunotherapy not including provision of allergen, extracts; single injection.

    Some Practices Limit Use of 99211

    Some practices choose not to assign 99211 even when it is appropriate such as a TB skin test as a public-relations gesture to patients. However, Jackson warns of the repercussions this can have. "Many practices especially those in low-income and rural areas want to be 'nice guys' to their patients," she says. "However, at the end of the month, after they've provided services without assigning 99211, internal medicine practices can find it hard to meet their financial obligations. They have bills to pay, salaries to pay, lab machinery to maintain, insurance obligations. None of these groups give their services away, so why should doctors? Bottom line: Practices need to charge for services they provide."

    Don't Report Both 99211 and Additional E/M Codes

    Sometimes an appointment that began as a nurse visit escalates. Perhaps the patient's blood pressure is significantly elevated or the nurse observes a possible infection when changing a dressing. Instances like these demand a physician's attention and will probably include a physical exam, history and increased medical decision-making. Tammy Chidester, CPC, billing supervisor, Upshur Medical Management Services Inc., a multispecialty physicians group and subsidiary of St. Joseph's Hospital in Buckhannon, W.Va., says these components justify a higher-level E/M code perhaps a 99212 or 99213. "Because the initial visit turns into a doctor's visit, coders cannot bill for the nurse visit (99211). Instead, internal medicine coders should report only the physician's service with a higher-level E/M code," she says.

    99201 Used in Limited Situations

    Although not reported as often, 99201 is used to report limited new patient encounters. Because the patient has not been seen before, the physician or NPP must provide the care, and document a problem-focused history, problem-focused exam and straightforward medical decision-making. This is a rare situation because, even if no major problem prompted the visit, the physician will probably conduct a thorough exam and history which would represent a higher-level E/M service.
     
    Chidester cites a typical example of 99201's application: A person is away from home and in need of a prescription refill. A physician conducts a limited exam and refills the prescription. "Another example is a new patient who comes in for an initial office visit with sunburn that requires first aid. The visit is focused, and the doctor treats the specific issue," she explains.

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