Medicare Compliance & Reimbursement

Hint: In rare cases, 99211 can be used for a Rx pickup.

Medicare providers likely report 99211 every time a practice nurse or medical assistant sees a patient. And yet despite the code’s prominence, you may be unaware of the subtle nuances necessary to bill it correctly.

Check out the following quick tips to ensure that you’re reporting 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 healthcare professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services …) properly every time.

Tip 1: Know When An Rx Pickup Warrants 99211

Some practices report 99211 any time a patient comes in for a “quick visit” — and that could be just to pick up a prescription or to hand in a form for the doctor to fill out. But not all of those speedy meetings warrant the use of 99211, even though there are exceptions.

“In the description of this code, it states, ‘for the evaluation and management of an established patient’ — picking up a prescription or handing in a form could be done at the front desk and don’t require any face-to-face time with a doctor or nurse,” says Rebecca L. Odell, CPC, CPCO, CPMA, CPB, CPC-I, billing team leader with Advanced Health Partners, Inc. in New Windsor, New York and president of the AAPC’s New Windsor chapter.

“If, however, the nurse meets with the patient to review the prescription to make sure the patient is properly educated on how to take the prescription, review side effects, etc., then it could qualify,” Odell says. “The code states, ‘typically, five minutes are spent performing or supervising these services,’ so it’s okay if the visit or face-to-face time isn’t long, but enough has to happen that a progress note can be written.”

Tip 2: Don’t Submit 99211 for New Patients

Keep in mind that 99211 only applies to established patients, not new ones. If you see a new patient for a level one visit, you’ll instead report 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 components …), but nurses cannot use that code.

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 3: The Physician May Report 99211, Too

Although you are likely to refer to 99211 as the “nurse’s code” the reality is that it isn’t limited to use by nurses.

Even though 99211 provides nurses and other clinical staff members with a mechanism to report services rendered to patients, physicians can bill it as well, says April Callahan, BA CPC, CPC-I, president and CEO of A&L Medical Coding Consulting, LLC, in Long Beach, Mississippi.

“The documentation of the 99211 visit does not have any specific key-component requirements, but you need to include sufficient information to support the reason for the encounter with any relevant history, physical assessment, and plan of care,” Callahan advises.

For instance: The physician examines a 65-year-old female patient during a preoperative exam and finds that her blood pressure is high. He decides to put her on medication to correct the problem. He 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 medicine is working, and follow-up. The physician’s notes indicate medical necessity for reporting 99211 when the patient returns. In this case, you could report 99211 for the low-level visit to check the patient’s blood pressure, assuming the documentation justifies it.

Some Medicare contractors expect documentation of vital signs when reporting 99211. In addition, medical necessity for the visit should be easily identifiable upon reading the medical record.