Part B Insider (Multispecialty) Coding Alert

Don’t forget to collect a copay when you see the nurse.

The nurses at your practice may be the backbone of the patient operations, but if you don’t know how to bill for their services, you’re shorting yourself out of a significant amount of cash.

Although almost every Part B practice employs a nurse, many of them are unclear about how to report nurse visits. We’ve gathered four of the most common questions that subscribers have submitted to the Insider on this topic, and provided expert answers below.

Weight and Vital Signs Won’t Cut It

Question: Our nurses circle 99211 for all labs and most injections. They believe that if they take the patient’s weight and vital signs, they can bill the nurse visit for all carriers. Is this the case?

Answer: No it isn’t. For you to ethically report 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...), the nurse must provide a medically indicated E/M service on the day of the injection or blood draw for labs. Merely recording the patient’s weight and vitals will not suffice.

On the other hand, if the nurse answers the patient’s questions about her treatment or reviews her medication regimens, you can submit 99211 as long as the nurse documents her patient interactions. This kind of documentation represents a minimal E/M service, which is the only time you should bill 99211. If the nurse doesn’t document her service, most carriers will disallow the code when they audit the claims.

Say Yes to Copay

Question: Should we collect a copayment for a visit with a nurse?

Answer: Yes, you must collect a copayment if the visit with the nurse is a chargeable, medically necessary visit. In other words, if the visit with the nurse is coded and charged, the patient must pay the copayment.

That does not mean, however, that a practice can charge for every patient who sees the nurse and collect a copayment. For example, if the patient sees the nurse for a blood-pressure measurement because the physician, as a courtesy, told the patient to stop in any time and have the check, there is no medical necessity to code the visit and, therefore, it is not charged. As a result, no copayment can be collected. But, if the physician gives written orders that a patient needs to come in for blood-pressure checks and medication monitoring with the nurse on a specific time-based schedule, medical necessity exists to code the nurse visit and charge it. The copayment must be collected. 

Nurses Can’t Choose From E/M Range

Question: A patient presents for straight catheter teaching. The nursing staff does the education. In order to bill an E/M, what would need to be documented in the patient’s chart? Would we bill 99211 or 99212? I am leaning toward 99211 because it is only education. 

Answer: The highest code a nurse can bill is 99211, no matter how much time she spends with the patient. The documentation must include a brief history and physical examination performed as well as a plan of care. All must be included in the chart documentation as well as the teaching. The physician must be in the office suite to provide supervision if required.

In black and white: “The medical record must be adequately documented to reflect the reason for the patient’s visit and any treatment rendered,” Noridian Medicare says in its 99211 Fact Sheet. “There must be recorded elements of history obtained, examination performed and/or clinical decision making, as well as physician supervision.”

If the nurse performs a straight catheterization during the teaching, you may also bill 51701 (Insertion of non-indwelling bladder catheter [eg, straight catheterization for residual urine]). Add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99211. Whether or not you are paid for the catheterization and E/M service will depend on the payer and your documentation.

Normal Test Results May Not Require Nurse Visit

Question: Can a nurse bill for a 99211 when the patient comes back for normal test results and abnormal test results? How about for an injection?

Answer: If the patient has an abnormal result, the provider who is giving her care should see the patient. You should not typically bring in patients to give them normal results, as there is no medical indication for doing so.

If an RN gives an injection and no other services, you should bill only the administration code 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular), not 99211. “If the sole purpose of a visit to the physician’s office is to draw blood or receive an injection, then 99211 should not be billed and only the appropriate injection or blood drawing code should be billed,” Noridian says.

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