Orthopedic Coding Alert

Here’s why 99211 descriptor change might seem minor … but it’s not.

Coders should be careful not to gloss over one key change when CPT^® 2022 takes effect on Jan. 1, 2022. It involves a seemingly innocuous change to a low-level office/outpatient evaluation and management (E/M) service.

Which one? The revision in question of the level one office/ outpatient E/M code for established patients. In 2022, the descriptor will read 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.).

2021 descriptor: (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. Usually, the presenting problem(s) are minimal.)

The difference: The phrase “Usually, the presenting problem(s) are minimal.” has been deleted. “The reason for the deletion is an editorial revision to bring the descriptor for 99211 more into line with the rest of the office/outpatient evaluation and management (E/M) codes. The descriptors for those codes prior to 2021 all included a sentence that read, ‘Usually, the presenting problem(s) are....’ Now, they don’t,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

With the phrase removal, 99211’s descriptor is now more synched with the other office/outpatient E/Ms: 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. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.).

“This change also removes a potential source of confusion,” says Cindy Hughes, CPC, CFPC, consulting editor of Cindy Hughes Consulting in El Dorado, Kansas. “For instance, 99211 may be reported when a nurse provides education to a newly diagnosed diabetic, but diabetes is by no means a minimal problem.”

In other words, even with the change, “99211 still represents an E/M (really an assessment and management) service provided by clinical staff as opposed to a physician or other qualified healthcare professional who may report higher levels of E/M services. Services described by 99211 must be medically necessary (i.e., clinically indicated) and be part of a plan of care by a physician or other qualified healthcare professional. This is why 99211 is not reportable for measuring a patient’s blood pressure at their request rather than per an established plan of care,” Hughes elaborates.