Ophthalmology and Optometry Coding Alert

Question: I have been reporting all services performed by our nurses, including those provided to new patients, with 99211. Is coding this way correct?

Oklahoma Subscriber

Answer: While 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) does not require history, exam, medical decision making (MDM), or the presence of a physician, automatically reporting services provided by a nurse with 99211 is not correct and could result in audits and revenue loss for your practice.

First, take a look at the code descriptor, which specifies 99211 is for an established patient, not a new patient. When reporting a new patient office visit, you should instead turn to the code group starting with 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making …).

Also, new patient encounters typically require the expertise of a physician or other eligible qualified healthcare professional (QHP) since the patient and their conditions are not known to the practice’s providers. Plus, reimbursement is typically higher for a new patient visit at the same level (e.g., 99202 versus 99212) because of the extra work and time it takes to gather all the information and make a diagnosis.

Remember: Medicare regards certain services provided by someone other than a physician or QHP as incident-to the physician or QHP, which you cannot report for a new patient. One of the many requirements for incident-to reporting is that there must be a previously established course of treatment in place, which wouldn’t be the case for a new patient.