Orthopedic Coding Alert

Learn 99211's requirements to decide whether your patient visits warrant it

Because orthopedic practices often delegate simple patient visits to a nurse, you might think you're familiar with all of 99211's nuances. But you shouldn't report 99211 until you're sure the visit meets the criteria.
 
You can report 99211 with confidence as long as you apply the code only when the practitioner provides a medically necessary service to an established patient. And remember, although this code is often referred to as the "nurse's code," your orthopedist and other personnel should report it if an E/M visit doesn't meet the documentation requirements of the higher-level E/M  codes (99212-99215).

Coding experts recommend that you 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. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) if the service meets three criteria:

1. Staff Performs an Actual E/M Visit

To report 99211, a practitioner must perform an evaluation and management service, so don't use 99211 simply to get any simple service paid, says Quinten A. Buechner, MS, MDiv, CPC, CHCO, president of ProActive Consultants LLC in Cumberland, Wis.

Suppose a nurse speaks to a patient on the phone and agrees to write him a prescription refill. He comes to the practice an hour later, and she hands him the prescription through the reception window.

Because the nurse did not evaluate the patient and no medical necessity required that she meet with him, she should not report an office visit.

But if the nurse couldn't renew the patient's prescription without evaluating him, she should have documented the medical necessity to support billing 99211. "I advise physicians that for nurse visits, the nurse should 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.

Look for notes such as "Wound has healed well," "Blood pressure is normal," or "Condition controlled with medication" to serve as proof that the practitioner met with the patient.

Any qualified personnel who are employees of the physician can report 99211, including medical assistants, licensed practical nurses, technicians and other aides working under the physician's direct supervision.

2. The Service Is Medically Necessary

Suppose your orthopedist applies a wrist splint and teaches the patient how to remove and apply the splint herself. The following day, the patient showers and cannot reapply the splint properly afterward. She returns to the office, where the nurse demonstrates the proper way to apply the splint. The nurse should report 99211 for this service. Not all nurse visits will warrant reporting 99211, however. Suppose the patient phones your office and reports that the splint tore at the seam. She returns to your office, where the nurse hands her a new splint. Because the nurse simply hands her the new splint, you should not report 99211.
 
3. The Patient Is an Established Patient

The new patient E/M codes do not offer an equivalent to 99211. Registered nurses cannot report 99201, the lowest-level new patient office visit code, because physicians must see new patients, or established patients who have new problems, before you can report 99211.