Ob-Gyn Coding Alert

Here's what the nurse needs to document.

Having a nurse on staff at your ob-gyn practice is essential to maintaining patient flow and handling clinical responsibilities, and many ob-gyn offices have more than one on staff. To ensure that you're able to collect for these essential encounters, you must keep a few best practices in mind.

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 health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services ...) properly, along with an example on reporting this code correctly.

1. An Actual E/M Visit Is Required

To report 99211, a practitioner 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 and no medical necessity required that she meet with her, you should not report an office visit. If the nurse couldn't renew the patient's prescription without evaluating her, however, she should have documented the medical necessity to support billing 99211.

Whenever you report 99211, the nurse should document the reason for the visit, a brief (interim) history of the patient's illness, any pertinent physical exam (vital signs are commonly expected by contractors in note audits of 99211). A brief evaluative statement (e.g. "vaginal itching much improved, no complications, vaginal cream being used daily, refill provided") is good practice.

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.

2. Re-Read the Code Descriptor

In the description of this code, it 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 and don't require any face-to-face time with a doctor or nurse, that doesn't meet the code's requirements.

In some cases, a prescription pickup or form completion could require an E/M visit to take place, and in those cases, 99211 is appropriate if the documentation supports it.

For instance, if a patient presents to pick up a 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. 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 and that some brief physician's time to supervise the service is warranted.

3. Remember That 99211 Applies to Established Patients Only

You shouldn't forget the fact 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.

4. Physicians Can Report This Code

When necessary, the ob-gyn 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 to reflect very limited history and/or physical exam and straight-forward medical decision making, such as renewing a low-risk medication.

5. Some Payers Bundle 99211 Into Certain Services

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

For instance, CGS Medicare says on its website, "Code 99211 is always bundled with injection administration procedures. CMS guidelines specify that the administration of injections is only paid separately when there is no other physician fee schedule service paid on that date of service for that provider."

Test Yourself: Code This Example

A patient picks up a birth-control refill and tells the receptionist that the medication causes some unpleasant side effects. The nurse documents the problem and checks with the ob-gyn regarding changing the patient's dose.

Solution:  This is an appropriate description of 99211, assuming the nurse documents the visit thoroughly.

Do this: To avoid any payer queries, include this documentation on medication checkup E/Ms:

• A record of patient's blood pressure, if relevant, and other vital signs
• A note indicating the clinical reason for checking blood pressure or other vital signs
• A list of the patient's current medications (include level of patient compliance, if possible) proof that the ob-gyn evaluated the clinical information the nurse obtained and made a management recommendation for the patient.