Neurosurgery Coding Alert

If a visit warrants 99211,you can recoup an additional $20 or more

Surgeons and other personnel -- not just nurses -- should report 99211 if an E/M visit doesn't meet the documentation requirements of the higher-level E/M codes (99212-99215). Additionally, you should apply 99211 only when the practitioner provides a medically necessary service to an established patient.

Coding experts recommend that you 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.) if the service meets three criteria:

To report 99211, a practitioner must perform an evaluation and management service. Don't use 99211 simply to get any simple service paid, says Quinten A. Buechner, MS, MDiv, CPC, CHCO, president of ProActive Consultants LLC in Cumberland, Wis. For example, if the nurse provides a patient with instructions over the telephone, you cannot report an E/M service.

"I advise physicians that for nurse visits, the nurse should document the reason for the visit, a brief history of the patient's illness, any exam processes such as weight or temperature, and a brief assessment," says Jay Neal, an independent coding consultant in Atlanta. If the nurse does this, you can report 99211 and recoup and additional $20 or more for the visit.

Look for notes such as "Wound has healed well," "Blood pressure is normal," or "Condition controlled with medication" to serve as proof that the practitioner met with the patient.

It's NOT just for nurses: Any qualified personnel who are employees of the physician can report 99211, including medical assistants, licensed practical nurses, technicians and other aides working under the physician's direct supervision.

Suppose the neurosurgeon sees an elderly patient with a minor infection at the site of a recent spinal puncture. The surgeon shows the patient how to apply antibiotic to the wound and change the dressing. The following day, the patient attempts to change the bandages but cannot. She returns to the office, and the nurse reapplies the dressing for the patient. The nurse should report 99211 for this service.

Not all nurse visits will warrant reporting 99211, however. Suppose the patient phones your office asking for more antibiotic cream. She returns to your office, where the nurse hands her a new tube of medication. Because the nurse simply hands her more antibiotic cream, you should not report 99211.

The new patient E/M codes do not offer an equivalent to 99211. Registered nurses cannot report 99201, the lowest-level new patient office visit code.

Remember: A physician must see new patients, or established patients who have new problems, before you can report 99211. For example, an established patient who had previously undergone surgery to correct carpel tunnel arrives at the office with a new complaint of lower-back pain. Even if the complaint is minor, the surgeon must see the patient because this is a new problem. On a subsequent follow-up visit for the same problem, however, the nurse could see the patient and report 99211.