Oncology & Hematology Coding Alert

Question: I reported 99211 for a nurse visit with a Medicare patient when our oncologist was out at lunch. My office manager said we can’t report 99211 this way, but I wasn’t sure if that’s true. Can you help me?

Washington Subscriber

Answer: Your office manager is correct. For Medicare claims, the physician must physically be in the office at the time of the service. They don’t necessarily have to be right by the nurse’s side, but they have to be somewhere in the office suite and immediately available should the physician or other qualified supervisor (billing) provider who is listed on the claim be needed for you to 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 or other qualified health care professional…) to the Part B payer.

In addition, you should report 99211 only for established patients — never new patients. This code 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.

Get the scoop: Incident-to, in relation to the 99211 service, means that a provider (the nurse practitioner, physician assistant, physician, etc.) previously saw a patient, and the patient is returning for a specific service based upon the treatment plan developed that previous visit.

Important: If the same physician who provided the original treatment plan is not the supervising physician during the patient’s return visit, the service must be billed under the physician who is supervising the services rendered on day and time the patient is seen for the follow up care.

For example: The physician’s treatment plan states that they want the patient to come back for a blood pressure check and to assess whether they are having problems with their new medications. The patient returns to the office and their blood pressure has improved. Also, their medications are not bothering them. The provider (perhaps a nurse or a medical assistant) documents that they saw the patient, took their blood pressure, and found that the patient is doing fine with their medications. The rendering provider / clinical staff who saw the patient must report all of this information to the physician. So, although the physician doesn’t have to see the patient, they must receive information about the encounter from the provider. The 99211 code could then be billed under the physician who provided the supervision and was in the office that day.