Medicare Compliance & Reimbursement

Hint: The 'nurse visit' code isn't just for nurses

If you are one of the many coders confused about when to use CPT code 99211, it's time for a reality check. Many people fail to use 99211 when they should, or they'll use it incorrectly. The following 99211 myths can help you report this code correctly every time.

Fact: Physicians, nurse practitioners, and physician assistants can use 99211 as well as nurses. If a non-physician bills under the billing physician's name using 99211, you still have to make sure you follow the "incident-to" regulations. Ensure that your documentation actually supports the use of 99211.

Myth: You should automatically use 99211 to bill for allergy shots and vaccinations if the provider did not provide any other service.

Fact: You can't bill 99211 for just an allergy shot or vaccination. For allergy shots, you should code 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) for a single shot or 95117 (...2 or more injections) for two or more shots. If the billing provider provides the allergy serum, then you should bill for the serum at the time the provider makes the new serum. For vaccinations, bill the vaccine separately and use 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]) for a single injection, 90473 (Immunization administration by intranasal or oral route; 1 vaccine [single or combination vaccine/toxoid]) for a single nasal/oral vaccination, or +90472 for each additional vaccination.

Note: If the nurse has to "check vitals" to make sure the injection is the correct quantity or if the nurse has to educate the patient about the administration or side effects of the injections, then you can bill for these services using 99211. Make sure the documentation supports these services.

Fact: The "incident-to" rules do apply to 99211, in order for a physician to bill for the services of a nurse or non-physician practitioner.

The person performing the service must be an employee or contractor of the billing physician or group under which you're billing the service. Also, the service must be in the physician's office, and the physician must be "in the suite" during the service. The physician must have prescribed the service, and the patient must be an established patient.

Myth: Nurses can bill for all levels of evaluation and management (E/M) visits as long as the physician is "in the suite."

Fact: Physicians can only bill for the services of nurses using 99211 under the "incident-to" regulations. Under "Incident to," physicians can bill for the services of nurse practitioners, clinical nurse specialists, and physician assistants for all levels of E/M services.