Medicare Compliance & Reimbursement

If your physician waives charges for patient visits with a nurse, you could be costing your practice deserved reimbursement.

Remember that to 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. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services), the person providing the care must have the necessary training to perform an E/M service, the documentation must show medical necessity, and the patient must be established to your practice.

But also keep in mind that to document medical necessity for 99211, the practitioner must perform an actual E/M service -- you can't bill the code just to get any simple service paid.

Not just for nurses: Remember that if the physician performs services that qualify for a 99211 but not a 99212, you can still bill 99211. "People think of this as the nurse's code, but the physician can bill it if he has only documented the necessary requirements for a 99211," says Atlantabased coding consultant Jay Neal.

Think you've learned how to use the lowest level E/M code? Check out four common Part B scenarios and determine whether you should report 99211 under these circumstances:

Scenario 1: A patient drops off a urine specimen.

What to do: You shouldn't charge 99211 for a urine specimen drop-off because the nurse doesn't perform an E/M service, says Beth Eisenshtat, patients account manager for Planned Parenthood of Nassau County in Hempstead, N.Y.

For the specimen handling and conveyance to an outside lab, however, you may be able to report 99000 (Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory) according to CPT Assistant, Oct. 1999, page 11. Some payers limit 99000 use to instances in which the practice incurs a cost in getting the specimen to the lab.

Scenario 2: A patient presents for a blood draw.

What to do: If the patient comes in only for a blood draw, you should charge 36415 (Collection of venous blood by venipuncture) instead of 99211. But you may report 99211 if the nurse takes the patient's history for a medically necessary reason or documents a chief complaint, and it was medically indicated to do so. Some carriers, however, may bundle the E/M service with the venipuncture code or vice versa.

Scenario 3: A patient picks up a medication refill and tells the receptionist that the medication causes some unpleasant side effects. The nurse documents the problem and checks with the physician regarding changing the patient's dose.

What to do: Because the service involves the nurse and a problem, you can most likely report 99211.

Scenario 4: A nurse administers a Lupron injection.

What to do: Usually, the administration code (96372, Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) covers the nurse's work, so you shouldn't submit 99211 as well.

In black and white: "Pay separately for the drug injection code only if no other physician fee schedule service is being paid at the same time," CMS notes in Transmittal 147. "If CPT code 99211 is billed with a drug injection code, pay only for 99211."