Medicare Compliance & Reimbursement

Tip: Documentation is key.

When employed properly, 99211 can allow certain qualified professional staff in your practice to handle low-level E/M visits. This allows physicians to focus on higher-complexity patients and helps your office run smoothly.

If you understand how to use it, the established patient office evaluation and management (E/M) code 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) could be a big contributor to your practice’s bottom line.

As with every code, there are rules to be followed on 99211 reporting. Use this list of tips to streamline and maximize your 99211 reporting.

Tip 1: Prove Entire E/M Visit Via Documentation

To report 99211, the clinician must perform an E/M service. In other words, it isn’t a catch-all code that you can report every time a patient passes through your practice.

Example: A nurse speaks to a patient on the phone and agrees to obtain a prescription refill for her. The patient comes to the practice an hour later, and the nurse hands her the prescription through the reception window.

Solution: Because the nurse did not evaluate the patient, you should not report an office visit. Whenever you report 99211, the provider should document the reason for the visit, along with any other pertinent details. Also, make sure you have the date of service, the reason for the visit, proof that the nurse performed the service per the physician’s order, and the nurse’s legible signature.

Tip 2: Be Familiar With 99211 Components

The description for 99211 states, “for the evaluation and management of an established patient.” When patients come in and weigh themselves, or simply hand you a form for the doctor to complete when no face-to-face time with a physician or nurse is required, 99211 does not apply.

In some cases, a prescription pickup or form completion could require an E/M visit to take place; in those cases, 99211 is appropriate if the documentation supports it. Report the appropriate E/M code for the physician exam provided.

For instance, if a patient presents to pick up a written prescription and the nurse meets with the patient to review the prescription to make sure the patient is properly educated on how to take the medication, review side effects, etc., then it could qualify.

Tip 3: Remember ‘Established Patient Rule’

You shouldn’t forget the fact that 99211 only applies to established patient visits, not new ones. Code 99211 is only for established patients because it is technically performed incident-to, meaning the ancillary staff nurse will be using the supervising provider’s billing information to get the practice paid for the work. To meet the guidelines associated with incident-to, the patient must have a plan of care that has already been created by a supervising provider. The nurse would be providing services directly indicated and/or appropriate to the plan of care.

Tip 4: Physicians Can Report 99211

When necessary, a physician or other qualified nonphysician practitioner (NPP) can use 99211, despite the fact that many practices refer to it as a “nurse’s code.” Any qualified personnel can report 99211, including physicians, medical assistants, licensed practical nurses, technicians, and other aides working under the physician’s direct supervision, depending on state law.

Most typically, a physician providing a brief service would utilize 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) to reflect the limited work they perform.

Tip 5: Look Out for Bundles

Although 99211 is often the best choice when a clinician performs a quick, medically necessary visit, payers won’t always reimburse it. The National Correct Coding Initiative (NCCI) bundles 99211 into several other codes, and some payers maintain their own edits for it.