Ob-Gyn Coding Alert

Use the code's requirements to decide whether your patient visits warrant it

Ob-gyn practices often delegate simple patient visits to a nurse, so you might think you're familiar with all of 99211's nuances. But you shouldn't report 99211 until you're sure the visit meets the criteria.

You can report 99211 with confidence as long as you apply the code only when the practitioner provides a medically necessary service to an established patient and the practitioner has the training or necessary credentials to perform the service according to state and payer requirements. And remember, although we often refer to this code as the "nurse's code," your ob-gyn and other personnel should report it if an E/M visit doesn't meet the documentation requirements of the higher-level established patient E/M codes (99212-99215).

In addition, some Medicare carriers, such as HGSA, the Part B carrier for Pennsylvania, have issued a clarification regarding 99211 use, says Mary Mulholland, BSN, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia. "Our carrier is restating the requirement of the physical presence of the physician in the office when the service is provided (to provide direct physician supervision) whenever this code is reported."

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:

1. Staff Performs an Actual E/M Visit

To report 99211, a practitioner must perform an E/M service, so don't use 99211 simply to get any simple service paid.

Example: A nurse speaks to a patient on the phone and agrees to obtain a prescription refill for her. She comes to the practice an hour later, and the nurse hands her the prescription through the reception window.

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. But if the nurse couldn't renew the patient's prescription without evaluating her, she should have documented the medical necessity to support billing 99211.

Anytime you report 99211, 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.

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.

Any qualified personnel who are employees of the ob-gyn can report 99211, including medical assistants, licensed practical nurses, technicians and other aides working under the physician's direct supervision.

2. The Service Is Medically Necessary

Suppose your ob-gyn applies a dressing to a surgery site and teaches the patient how to remove and apply the dressing herself. The following day, the patient showers and cannot reapply the dressing properly afterward. She returns to the office, where the nurse demonstrates the proper way to apply the dressing.

The nurse should report 99211 for this service. But not all nurse visits will warrant reporting 99211. Suppose the patient phones your office and reports that she misplaced the dressing material the doctor had provided. She returns to your office, where the nurse hands her new dressings. Because the nurse simply hands her the new material, you should not report 99211.

"What the payer expects to see if they were to review the medical records is that the service provided required more than simply collecting a specimen or the administration of an injection," says Judy Richardson, MSA, RN, CCS-P, senior consultant with Hill & Associates in Wilmington, N.C. "A bit more expertise should go into the record."

3. The Patient Is an Established Patient

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, because physicians must see new patients, or established patients who have new problems, before you can report 99211.

"Remember, however, that Medicare [and most other payers] does not pay for some services, such as 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) and 90788 (Intramuscular injection of antibiotic [specify]), with any E/M codes." Richardson notes. "This policy includes CPT 99211."