Internal Medicine Coding Alert

Answer: The CPT definition of 99211 is 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.

Missing from that CPT definition is the history, examination and medical decision-making components that are required of most other evaluation and management (E/M) codes. Because the CPT manual states that the presence of a physician is not necessary, the code is often used to bill services by a nonphysician provider, such as a registered nurse.

When the nurse is administering a prothrombin test, 99211 could be reported if the nurse discusses information about the patients present dosage of medication, or the continuation or change of dosage, according to William K. Dettwyler, MT, an independent coding consultant in Salem, Ore. It can also be used when the nurse discusses with the patient any problems and concerns that ordinarily would be addressed by the physician. With a patient on long-term anticoagulant therapy in which the control is very stable, reporting this code may not be appropriate every time the patient is tested.

To bill this service to Medicare, however, there must be direct supervision of the service by the internist. Services provided by a nurse that are covered by Medicare are billed incident to a physicians professional services. The Medicare Carriers Manual, section 2050.1(B), stipulates that to bill incident to, there must be direct supervision of the service by the internist. Although direct personal supervision in the office does not mean that the internist must be present in the room when the service is administered, it does mean that the internist must be in the office suite and immediately available to provide assistance and direction if needed.

Finally, some local Medicare carriers, such as Blue Cross Blue Shield of Alabama, do not reimburse for E/M services provided by a nurse. A March 1997 special bulletin issued by the carrier states that although the Physicians Current Procedural Terminology (CPT) book specifies that office visit code 99211 may be used for visits that may not require the presence of a physician, a physician should not bill for an office visit if only the assistant or nurse actually sees the patient. This is true whether or not the physician is in the office at the time.