Orthopedic Coding Alert

If you-re using it only for nurse visits, you could be losing out

You may think of 99211 as the -nurse's code,- but you could be using it for other situations. And if you can report it, you should, experts say.

Code 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) differs from the other office visit codes in that it does not require the three E/M components. In addition, the code descriptor specifies that the visit -may not require the presence of a physician.- Use these criteria whenever you report this code.

Actual E/M Service Is a Must-Have

Most medical practices report 99211 for brief but medically necessary visits with a nurse or other applicable nonphysician practitioners (NPPs), such as physician assistants (PAs), nurse practitioners (NPs) and certified nurse specialists (CNSs). The NPP must perform the E/M service, however, so you don't use 99211 simply to get a service paid.

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

Coding solution: Because the nurse did not evaluate the patient and no medical necessity required her to meet with the patient, you should not report an office visit for this service, according to Suzan Hvizdash, BS, CPC, CPC-EMS, CPC-EDS, physician educator for UPMC, University of Pittsburgh Physicians- department of surgery. On the other hand, if the nurse couldn't renew the patient's prescription without evaluating her, she should have documented the medical necessity to support reporting 99211.

Look for key phrases: Anytime you report 99211, the NPP should document the reason for the visit, a brief history of the patient's illness, any exam elements such as weight or temperature, and a brief assessment. Check the documentation for notes like, -Wound has healed well- or -Swelling has decreased,- to serve as proof that the practitioner met with the patient, says Linda Martien, CPC, CPC-EDS, CPC-H, coding consultant with National Healthcare Review in Woodland Hills, Calif.

If a qualified mid-level provider performed the encounter, your code choices would include other E/M services as well (for example, 99212-99215), Hvizdash says.

In addition, make sure you have the date of service, the reason for the visit, proof that the NPP performed the service according to the orthopedist's orders, and the NPP's signature on the note. Although the history, exam and medical decision-making components are not directly part of this E/M service, there must be documentation, and it should still accurately and thoroughly paint a picture of the visit, Hvizdash adds.

Keep in mind: You can report 99211 for any qualified practice employee's services, including medical assistants, licensed practical nurses, technicians and other aides as long as they are working under the physician's direct supervision. -This could also provide additional reimbursement to your practice if this isn't already done,- Hvizdash says.

You Can't Avoid Medical Necessity

-Don't assume you can use 99211 for all nurses- visits, or you could land in compliance hot water,- says Jill M. Young, CPC-EDS, of Young Medical Consulting LLC in East Lansing, Mich.

Coding scenario: Your orthopedist recently changed a patient's anti-inflammatory medication and wants her to return in a week to meet with the nurse so she can evaluate its effect on the patient before the physician writes a three-month prescription renewal. The nurse documents that the patient is responding well to the new medication after a brief examination and assessment. In this case, you can report 99211 for the nurse's services.

On the other hand, if patients merely call in their response to the medication and speak at length with the nurse, you would not be able to report this service using 99211 because there was no face-to-face encounter, Hvizdash says.

Patient Must Be Established

CPT doesn't offer a new patient E/M code equivalent to 99211. Specifically, NPPs can't report 99201, the lowest-level new patient office visit code, incident-to because your orthopedist must see new patients and establish a course of treatment that the NPPs would follow in the additional visits. The same rule holds true for established patients who report to your practice with new problems.

-Part of the rules for using 99211 is that your physician has established a treatment plan and medical necessity for the follow-up performed by the NPP. And this must be documented in the medical record,- Martien says.

Watch Your Payers- Guidelines

When reporting 99211 incident-to, make sure you-ve met your specific payer's supervision requirements for a 99211 service, Young says. For instance, Medicare requires that the physician be in the suite, whereas another carrier may require that the physician merely be available by phone.