Otolaryngology Coding Alert

Hint: This code only applies to established patients.

Code 99211 might be your go-to choice for everyday services ranging from medication updates to blood pressure checks, but don’t assume that the so-called “nurse visit” code is always your best option. Many MACs are scrutinizing 99211 claims and attempting to clarify when the code is – or isn’t – appropriate. Here’s what you need to know to keep your claims on track.

First things first: The descriptor for 99211 reads, “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. Typically, 5 minutes are spent performing or supervising these services.”

Understand the purpose: “Services billed to Medicare under CPT® code 99211 must be reasonable and necessary for the diagnosis and treatment of an illness or injury,” says a policy on 99211 written by Part B MAC WPS Medicare. “Furthermore, a face-to-face encounter with a patient consisting of elements of both evaluation and management is required. The evaluation portion is substantiated when the record includes documentation of a clinically relevant and necessary exchange of information between provider and patient. The management portion is substantiated when the record demonstrates an influence on patient care (e.g., medical decision making, patient education, etc.).”

Keep 5 Key Facts in Mind

In addition to understanding the intent of 99211, you should know who can report the code and under what circumstances. Start by remembering these five facts:

• Code 99211 is not just for medical assistants and nurses. Although it’s commonly referred to as the “nurse visit code,” in actuality, physicians, nurse practitioners, and physician assistants also can report 99211 when applicable.
• The patient must be established for the medical assistant, nurse and possibly the non-physician practitioner to bill 99211. If a non-physician bills under the billing physician’s name and NPI using 99211, you still have to make sure you follow the “incident-to” regulations, which means that it only applies to established patients with a plan of care by the physician (or NPP) and the physician must be on-site, in the suite, at the time of the visit to perform direct supervision.  
• Blood pressure checks only qualify for 99211 if you document certain specific items. Those items often are: documentation that blood pressure and other vital signs were reported; the clinical reason for checking the blood pressure; a list of the patient’s current medications; an indication of the doctor’s evaluation of the clinical information and his management recommendation; and the identity and credentials of the provider.
• Do not submit 99211 when clinical staff does not provide direct face-to-face contact with the patient. The face-to-face provider must be an employee, contractor, or leased employee operating under direct supervision (meaning a supervising physician or non-physician provider is in the office suite) with an order for the service and the ordering physician/practitioner identified.
• It is a good idea for any incident to personnel who are providing services under the direct supervision of either a physician or NPP to indicate at the beginning of the note who is in the office at the time of the service supervising the incident to personnel. A statement such as “Dr. Smith is in the office today supervising my services” goes a long way if the 99211 services are audited.