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Orthopedic Coding Alert

Think You're 99211 Savvy? Take Our Quiz to Find Out

Published on Sat Oct 09, 2004

If you're billing 99211 for injections, you may be coding incorrectly

How much do you really know about when to report 99211? Take the following short quiz, and then look at the box below to check your answers against those that our coding experts provided.

Questions

1. Which members of a practice's medical staff can 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)?

2. Should you use 99211 if you provide a service that has its own CPT code?

3. Can practices report 99211 for prescription refills?

4. When a patient comes in for an injection, can you bill 99211?


Answers

1. Many coders don't realize that they can bill 99211 to report services that clinical staff other than the nurse provides, says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver.

Any qualified "auxiliary personnel" who are employees of the physician (such as medical assistants, licensed practical nurses, technicians and other aides) and are working under the physician's direct supervision can provide services to patients under the incident-to umbrella using 99211. These clinicians can report 99211 as long as the patient visit meets the medical-necessity requirement for billing an E/M code.

Use Incident-to Rules With 99211

"Even though an NP, PA or even an MD/DO potentially can bill 99211, the bigger question should be why would one of these providers be providing the service to bill 99211," Hammer says. "This may not be a very efficient use of their time." If your physician's documentation frequently supports billing 99211, he may need to work on improving his documentation, she says.

The physician must be present in the office space, and the auxiliary personnel must be qualified to perform the service. Because your practice reports 99211 as an incident- to service, "the nurse would have to be monitoring a problem that the physician already evaluated," because you cannot bill incident-to if the nurse evaluates a new problem, says Malea Ivey, RHIT, coder at the Orthopedic and Neurosurgical Center of the Cascades in Bend, Ore.

Although CPT does not bar physicians from using 99211, they normally use higher-level E/M codes in most cases because of the greater complexity of care they usually provide.

Don't Assign 99211 as a Cure-All

2. If CPT assigns a code to the service that you perform, you should bill that code, not the nurse's code. For example, a patient comes to the office for a urinalysis and complete blood count the day before her scheduled surgery.

In this case, you should use 81002 (Urinalysis, by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy) and G0001 (Routine venipuncture for collection of specimen[s]) instead of 99211.

You cannot use 99211 for the time that the nurse spends with the patient unless she provides another medically necessary service in addition to the lab work. 

Coding consultants recommend that 99211 notes include:

  • Vital signs

  • The patient's chief complaint, if appropriate

  • Evaluation of the patient's medical condition

  • Description of the service provided

  • Name of the attending surgeon

  • Questions the patient asks and responses given

  • Notes on follow-up care.

    3. If the nurse or other office personnel has a medical reason to evaluate the patient when he comes in to pick up the prescription, you can report 99211. For example, you would bill 99211 if the physician recently changed the patient's medications and wants the nurse to evaluate the effect on the patient before the physician gives him a three-month prescription renewal of the medicine.

    Telephone calls and conversations about prescription renewals are two of the biggest 99211 abuses, says Denise Paige, CPC, coding manager at Beach Orthopedic Associates in Long Beach, Calif., and president of the American Academy of Professional Coders' Long Beach Chapter.

    Avoid 99211 for Injections

    4. Coders often disagree about whether to use 99211 or the 90782-90799 series (Therapeutic, prophylactic or diagnostic injections) when the nurse administers a shot, but the answer is clear: "If the patient came in for a planned injection and an injection was provided, the injection code should be billed," Ivey says.

    Medicare specifically says in 15502 (D) of the Medicare Carriers Manual not to use 99211 for injections, warning that the code "cannot be used to report a visit solely for the purpose of receiving an injection which meets the definition of CPT codes 90782, 90783, 90784 or 90788."

    If the orthopedist or his staff provides an E/M service along with an injection, Medicare says it will cover the E/M service but will bundle the injection administration (90782-90799) into the appropriate E/M code. In either case, you can report the J code that represents the drug that the nurse or other practitioner administers, Paige says.

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