Orthopedic Coding Alert

1. Know How 99211 Differs From Other Office/Outpatient E/Ms

Three things make 99211 different from the other office/ outpatient E/M codes. First, the code descriptor notes “a physician or other qualified physician [QHP] does not have to be present at the time of the encounter.” More on that later.

Second, the code descriptor does not require you to document a level of medical decision making (MDM). And third, you are not required to factor time into determining the encounter level.

Or, to put it another way, “99211 still represents an E/M,” according to Cindy Hughes, CPC, CFPC, consulting editor of Cindy Hughes Consulting in El Dorado, Kansas. But it’s “really an assessment and management service provided by clinical staff as opposed to a physician or other QHP who may report higher levels of E/M services.”

2. Know How to Document 99211

Even though you don’t have to document MDM or time when reporting 99211, that doesn’t mean you don’t have to document the details of the encounter. Like any level of office/outpatient E/M, you need to document the following:

• Why the patient is present and the purpose of the visit
• Medical necessity for the visit, including pertinent diagnoses and relevant history/exam information
• Any work the provider performed, including vital checks
• Anything the provider discussed with the patient, including discussion of medications

3. Know Who Can Perform 99211

You will usually report 99211 when a clinical staff member performs the service following a physician or other qualified healthcare provider’s initial service. Performance of the service is subject to the individual clinical staff member’s scope of practice as defined by each state’s regulations and payer guidelines.

But remember: While the language in the code descriptor states a physician or other QHP does not need to be present, that doesn’t mean a physician/QHP cannot perform the service. However, if a physician or other QHP performs the evaluation and management service, then you should generally report the appropriate higher level of care with an established patient office/outpatient E/M from 99212-99215.

4. Know When You Cannot Bill 99211

Once again, following the code descriptor to the letter will tell you when you should not use 99211.

First, 99211 is for an established patient. So, you should not use the code for an encounter with a new patient, even if the visit does not require a history, an exam, or MDM at any level.

Keep in mind: During the public health emergency, there was a waiver that allowed billing 99211 for a new patient who presented only for COVID testing services when a billing provider other than a physician or nonphysician saw the patient only for sample collection, but this allowance has now ended.

If a new patient comes in, it is best practice for a physician or QHP to see the patient as they will need to assess and initiate a care plan and report the appropriate level of new patient office/ outpatient E/M service with a code such as 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 total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) at a minimum. And only a physician or eligible QHP billing provider can provide those services.

Not only is this compliant coding, it’s also a smart business decision, “as the reimbursement is higher for a new patient at the same level of service,” due to the extra work typically involved in taking the patient’s history and diagnosing new conditions, explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. The 2024 national nonfacility fee for 99211, for example, is set at $23.30, whereas Medicare will reimburse 99202 at $72.23.

Remember: If someone other than a physician or other QHP provides an E/M service, Medicare regards the service as incident to the physician or other QHP, and you cannot provide incident-to services to a new patient. A major requirement for incident-to reporting is that there must be a previously established course of treatment in place, which can never be true for a new patient.

Second, the fact that 99211 does not require the presence of a physician or other QHP does not mean you can use it to report services provided to a patient by an administrative staff member. Again, you will need to be familiar with the scope of practice regulations your state and payer adheres to in determining who can, and who cannot, perform a 99211 service.

Last, you should never use 99211 if a different CPT^® code more accurately describes the service or for a non-face-to-face service. As we have just seen, 99211 is a code “for the evaluation and management of an established patient.” When patients come in and don’t require any face-to-face time with a physician or other QHP, such as for prescription pickup or form completion, this would not meet the 99211 code’s requirements.

In some cases, such visits could require an assessment visit. For example, if a patient presents to pick up a prescription and requests to speak with the provider about medication use, and a nurse meets with the patient to review the prescription to ensure the patient is properly educated on how to take the medication or to review side effects, you might be able to support 99211. In other words, enough has to happen at the encounter to support the medical necessity and content of the visit for the nurse to write a progress note that aligns with an established plan of care . The note should also include documentation of appropriate-level physician supervision to warrant billing the visit as 99211.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC