Oncology & Hematology Coding Alert

Experts answer 3 common questions for this troublesome E/M code

CPT offers code 99211 for evaluation and management of minimal problems, but the confusion over using this code has been far from minimal.

Get on the right track with this expert advice on the often-misused 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).

Consider 99211 to Be More Than Nurse's Code

Question: Which members of a practice's medical staff can report 99211?
 
Answer: Many coders don't realize that they can bill 99211 to report services that clinical staff other than the nurse provides, says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver.

Don't overlook: Any qualified -auxiliary personnel- who are employees of the physician (such as medical assistants, licensed practical nurses, technicians and other aides) and are working under the physician's direct supervision can provide services to patients under the incident-to umbrella using 99211. These clinicians can report 99211 as long as the patient visit meets the medical-necessity requirement for billing an E/M code.

Although CPT does not bar physicians from using 99211, oncologists normally use higher-level E/M codes because of the greater complexity of care they provide. If your physicians- documentation frequently supports reporting 99211, they may need to work on improving their documentation, Hammer says. -This may not be a very efficient use of their time.-

If an auxiliary personnel member performs an E/M service and plans to report 99211, the physician must be present in the office space, and the auxiliary personnel must be qualified to perform the service based on state scope of practice. Because your practice reports 99211 as an incident-to service, the provider would have to be monitoring a problem that the physician already evaluated, because you cannot bill incident-to if the nonphysician practitioner evaluates a new problem.

Medicare interpretation: The physician's presence is not required at each 99211 service involving a Medicare patient, but the physician must at least be in the office suite when each service is provided. The physician must also initiate the service as part of a continuing plan of care. He should be an -ongoing participant- in this care, which to some carriers means he must see the patient at least every third visit.

Watch for: New code 90772 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) includes an instruction that you shouldn't report 90772 for injections given without direct physician supervision. The instruction tells you to report 99211 instead. Problem: You need
direct supervision to report 99211, as well. We-ll keep you apprised of any clarifications the AMA issues on this instruction.

Base Blood Draw Coding on Circumstances

Question: If a patient arrives for chemotherapy and a provider must address a problem with a blood draw, can you report 99211?
 
Answer: Private payers vary on their 99211 coverage, says Kelly Reibman, CPC, in the Easton, Pa., office of oncologist Mariette Austin, PhD, MD.

You typically can't report 99211 with chemotherapy, but for a private payer, you may be able to report 99211 on the same day as chemotherapy if you can identify a significant, separately identifiable service. Depending on your payer, you may need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Resources: Medicare Transmittal 147 tells you that on the same day as chemo administration or nonchemo drug infusion carriers pay for E/M services, other than CPT 99211, provided you meet certain criteria.

You-ll find this Medicare transmittal online at www.cms.hhs.gov/manuals/pm_trans/R147CP.pdf.

CMS reaffirmed this position in transmittal 731, dated Oct. 28, 2005, at www.cms.hhs.gov/manuals/pm_trans/R731CP.pdf.

CIGNA Medicare explains why you can't code 99211 with chemo administration in question 4 of its FAQ page at www.cignamedicare.com/partb/faq/mr/mr0404.html, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga. The site explains that the fee for 99211 has been added to the administration codes.

Outpatient hospital clinics will benefit from the information on when you should and shouldn't report 99211 offered by Veritus at www.veritusmedicare.com/provider/bulletins/general/2003/mpr03145.shtml.

Remember: If a patient is scheduled only for a blood draw, you shouldn't report 99211 for the service. Instead, report the code specific to that service, 36415 (Collection of venous blood by venipuncture).

Don't Use 99211 as a Catchall

Question: Can you report 99211 when a patient comes in for a prescription refill?
 
Answer: If the nurse or other office personnel has a medical reason to evaluate the patient when he comes in to pick up the prescription, you can report 99211. For example, you would report 99211 if the physician recently changed the patient's medications and ordered the nurse to evaluate the effect on the patient before the physician gives him a three-month prescription renewal.

However, telephone calls and conversations about prescription renewals are two of the biggest 99211 abuses, so you should never report 99211 just for a telephone conversation that a nurse has with the patient about the prescription, or if personnel simply hands the patient the prescription when he presents to your practice.

Protect yourself: Even though 99211 pays less than the higher-level E/M codes (99212-99215), you shouldn't skimp on your documentation. -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.