Orthopedic Coding Alert

Question: Should I be reporting all services performed by a nurse, including those provided to new patients, with 99211?

Ohio 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 itself, which says 99211 is for an established patient, not a new patient. New patients must be reported 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 …), at a minimum. Also, new patient encounters typically require the expertise of a physician or other eligible qualified healthcare professional (QHP) since neither the patient nor their condition(s) are known to those in the practice. Reimbursement is typically higher for a new patient visit at the same level (e.g., 99202 versus 99212 [Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.]) because of the extra work and time involved to gather all the information and diagnose any new conditions.

Also, remember that 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 of course wouldn’t be the case for a new patient.