Medicare Compliance & Reimbursement

Ensure that your documentation supports billing 99211.

Caution: Before you decide to bill 99211 for nurse visits, you need to make sure that you’re meeting all of the appropriate conditions for reporting this code. But don’t let that scare you off — not reporting 99211 when it’s appropriate to do so could make a significant difference to your practice’s bottom line.

Check the Code Criteria

The first key criterion for 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 health care professional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) is that the patient must be established. When capturing 99211 remember that at least one of your physicians in the same specialty and under the same group ID as the provider performing the service, must have seen the patient for a face-to-face service within the past 36 months.

The visits you can report using 99211 are usually for minor problems where the provider’s staff checks vitals, gives injections, or reviews current medications. When the provider becomes involved, she usually completes the face-to-face service in a short time period of five minutes or less. 

Note, however, that when a physician and staff provide a service, it usually turns into a problem focused history or examination and straightforward medical decision making, which allows you to report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) instead of 99211. 

Red flag: If a nurse sees a patient just prior to the patient seeing her physician, that nurse encounter is included in the E/M service the physician provides and is not a separately billable service. 

Don’t overlook: If you want to make sure that your practice is reimbursed for the visit, the patient must be established, the service must be medically necessary, and a well-documented E/M provided. To ensure the documentation supports billing 99211, your provider’s staff should include at least these five criteria:

• The date of the visit
• The name of the service provider
• The reason for the visit
• Brief exam; weight and temperature
• Brief assessment of the situation.

Profit: If you provide thorough information, you could get paid about $20 per 99211 encounter (0.56 total non-facility RVUs times the 2014 national unadjusted conversion factor of 35.8228). That may not sound like much, but if your practice performs five of these visits a week, after a year you’ve made or lost over $5,000.

Avoid Using 99211 in Some Circumstances

According to experts, there are at least three “don’ts” when it comes to reporting 99211 to Medicare:

1. Don’t use 99211 for a nurse visit for services that are a part of another E/M.

Example: A nurse measures the patient’s height, weight, and blood pressure before the physician sees the patient. The nurse’s work would be part of the physician’s E/M.

2. Don’t report 99211 for telephone calls to patients because there has to be a face-to-face contact.

Example: A nurse returns a patient’s phone call and gives instructions over the phone.

3. Don’t underestimate the impact the documentation can have on your reimbursement. When it comes to documenting 99211 visits, the report is critical. The care provider must provide the reason and the details for the encounter. This could include educational services or an evaluation of the patient’s condition with management of the condition being overseen by the physician.

Example: “Problems can occur when billing 99211 with a ‘routine BP check,’” says Catherine Brink, BS, CMM, CPC, CMSCS, president of Healthcare Resource Management Inc. in Spring Lake, NJ. “The medical record needs to state why the patient came in for a BP check.” 

To clearly state that there is medical necessity for performing 99211, the physician may document “patient BP not under control. BP meds increased to 300 mg. Patient is to return in three weeks for a BP check. If BP is still not under control, we will change his BP meds.” Note how that documentation differs from the physician documentation just stating “return in 6 weeks for BP check.” The latter only justifies a BP check and not an E/M, Brink explains. 

Final note: The definition of 99211 states it “may not require the presence of a physician or other qualified health care professional.” But that doesn’t mean a physician can’t provide the service. If the service a physician provides meets the definition of 99211, then that’s the appropriate code to use. Realistically, though, it’s extremely rare for a physician to provide a service that qualifies for only 99211. Normally documentation will support at least 99212 when a physician provides face-to-face care to a patient.