Ob-Gyn Coding Alert
99211 Must Include Minimal Service
Question: Our nurses mark 99211 for all labs and most injections. They believe that if they take the patient's weight and vital signs, they can bill the nurse visit for all carriers. Is this the case? Pennsylvania Subscriber Answer: For you to ethically report 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...), the nurse must provide a medically indicated E/M service on the day of the injection or blood draw for labs. Merely recording the patient's weight and vitals will not suffice. On the other hand, if the nurse answers the patient's questions about her treatment or reviews her medication regimens, you can submit 99211 as long as the nurse documents her patient interactions. This kind of documentation represents a minimal E/M service, which is the only time you should bill 99211. If the nurse doesn't document her service, most carriers will disallow the code when they audit.
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