Otolaryngology Coding Alert

Answer Three Questions to Resolve 99211 Payment Issues

Published on Wed Jan 01, 2003

By reviewing who performed the service, the service performed and the associated diagnoses, you can ensure that your otolaryngology practice receives proper payment when you report 99211 (Established patient office visit usually the presenting problems are minimal).

Remember that 99211 usually triggers a copayment, and your practice should inform patients of this. In addition, the code is for established patients.

1. Did Auxiliary Personnel Perform the Service?

"99211 is often called a nurse visit," says Catherine Brink, CMM, CPC, president of Health Care Resource Management Inc. in Spring Lake, N.J. It is the lowest-level E/M visit for an established patient and is typically used when the nurse sees a patient for a minor problem.

Although Medicare does not bar physicians and nonphysician practitioners, such as nurse practitioners and physician assistants, from using 99211, they will use a higher-level E/M code in most cases because of the greater complexity of care they usually provide.

Many coders don't realize that they can use 99211 to report services by office employees other than the nurse, says Kathy Pride, CPC, CCS-P, HIM applications specialist with the San Rafael, Calif.-based QuadraMed. Any qualified "auxiliary personnel" who are employees of the physician, such as medical assistants, licensed practical nurses, technicians and other aides, can provide services to patients incident-to the physician using 99211. To bill incident-to:

the staff must perform the service under the physician's direct supervision

the visit must meet the medical-necessity requirement for billing an E/M code.

Direct supervision means the physician must be present in the office when the auxiliary personnel perform the service. In addition, the staff person must be qualified to perform the service.

Note: For more on auxiliary personnel, read Section 2050.1 of the Medicare Carriers Manual.

2. Does a Code Describe the Service?

Coders frequently question whether they can use 99211 when a patient comes to the office for common procedures, such as allergy shots.

The first question the coder should ask is: Does the service that was provided have its own CPT code?

"If the service has an identifiable code, bill that code, and not 99211," Pride says.

Routine Hearing Checks Aren't Covered

For example, an established patient comes in complaining of dizziness (780.4) and sees the audiologist. She performs audiometric testing, including comprehensive audiometry threshold, impedance and acoustic reflex testing. In this case, report the CPT code for each test: 92557(Comprehensive audiometry threshold evaluation and speech recognition [92553 and 92556 combined]), 92567 (Tympanometry [impedance testing]) and 92568 (Acoustic reflex testing).

You cannot code 99211 for the time that the audiologist spends with the patient unless she provides another medically necessary service in addition to the hearing tests. For instance, the audiologist performs a "dizzy-patient workup" in which she tries to pinpoint the occurrences' exact history. In addition, the patient completes a neurotology questionnaire. The audiologist notes the workup and questionnaire results in the patient's chart. In that case, you should bill the appropriate audiological test code and 99211 appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

3. Does Medical Necessity Support an E/M Visit?

If the service provided to the patient by auxiliary personnel does not have its own identifiable CPT code, you may be able to use 99211. Because this code does not have required elements of history, examination and decision-making, many otolaryngology coders are unsure when and how to use it. The key is to establish the same medical necessity that payers require for all E/M codes. "Make sure you document what service was performed and the medical necessity for it," Pride says.

99211 Can Be a Prescription for Denial

Another frequent question is whether offices can assign 99211 for a prescription refill.

"Did the doctor write out the prescription and leave it at the front desk for the patient to pick up?" Pride asks. If the answer is yes and the patient simply picked up the prescription and left, the refill cannot be billed.

But if a medical reason exists for the nurse or other office personnel to evaluate the patient when he comes in to pick up the prescription, use 99211. For example, a doctor recently changed allergy medications and wants the nurse to evaluate the effect on the patient before giving him a three-month prescription of the medicine. The nurse evaluates the patient's response to the medication, possible side effects and consults the otolaryngologist for appropriate dosage adjustments.

Allergy-Shot Visits Present Sticky Issue

Coders are often unsure when to bill a nurse-visit code (99211) with the allergen immunotherapy codes (95115-95199) for shot-only visits. CPT's introduction to the Allergen Immunotherapy section clearly states that 95115-95199 "include the professional services necessary for allergen immunotherapy." The section further instructs that if you perform a significant, separately identifiable E/M service, "Office visit codes may be used in addition to allergen immunotherapy."

For instance, a patient has a local reaction to immunotherapy that requires additional history, dosage requirements and examination. Carefully document these services. Report the immunotherapy, such as 95120 (Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; single injection), and the nurse's evaluation (99211) appended with modifier -25.

Other circumstances may also qualify for 99211. For instance, an office requires that patients complete a questionnaire regarding their current status and condition prior to starting a new vial. The nurse reviews the questionnaire's results. If the patient is experiencing problems or not progressing, he schedules a doctor's appointment for a later date. You should bill 99211 for the questionnaire and review, says Pam Martin, administrator for Blue Ridge ENT and Facial Surgery in Princeton, W.Va. "The nurse provides a service and employs decision-making," she says. Document these services and the medical necessity for the nurse's actions to support billing 99211.