Part B Insider (Multispecialty) Coding Alert

Don't leave $19 per visit on the table -- follow these rules to ensure you collect what's due to you.

If your physician waives charging for patient visits with a nurse, your doctor could be costing your practice deserved reimbursement. All you have to do is follow these simple criteria for reporting 99211:

• the person providing the care has the necessary training to perform an E/M service

• the documentation shows medical necessity

• the patient is established to your practice.

Heads up: Our coding experts recommend that you 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. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) if the service meets these three principles:

To report 99211, a practitioner must perform an E/M service. In other words, don't use 99211 simply to get any simple service paid.

Example: A nurse speaks to a patient on the phone and agrees to obtain a prescription refill for her. She comes to the practice an hour later, and the nurse hands the patient the prescription through the reception window.

Solution: Because the nurse did not evaluate the patient and no medical necessity required that the nurse meet with the patient, you should not report an office visit, says Beth Eisenshtat, patients account manager for Planned Parenthood of Nassau County in Hempstead, N.Y. However, if the nurse couldn't renew the patient's prescription without evaluating her, then the nurse should have documented the medical necessity to support billing 99211. Any time you report 99211, the nurse should document the reason for the visit, a brief history of the patient's illness, any exam processes such as weight or temperature, and a brief assessment.

What to look for: Check the documentation for notes,such as "Wound has healed well," "Blood pressure is normal," or "Condition controlled with medication," that prove the practitioner met with the patient. Also, make sure you have the date of service, the reason for the visit, proof that the nurse performed the service per the physician's order, and the nurse's signature.

Did you know? Any qualified personnel who are employees of the physician can report 99211 -- so long as they are working under the physician's direct supervision.

Examples include registered nurses, licensed practical nurses, and other ancillary staff who have training to provide an E/M service.

2. The Service Is Medically Necessary If you think all nurse visits warrant using 99211, you could land in compliance hot water.

Example: A patient comes  into the office for a blood pressure BP) check because she recently had a high BP reading. Today's reading is normal.

Solution: Before you jump to a coding conclusion, you need to ask some questions. "Ask, was the prior BP reading documented as a problem? Did the patient have the BP taken elsewhere? If high BP is an ongoing problem, did any faceto-face time occur, or was this just a routine BP?" Eisenshtat says.

According to Medicare guidelines, billing 99211 for a simple blood pressure check that does not lead to management of a condition or illness, is not a billable E/M service. A medically necessary 99211 service for a blood pressure check, on the other hand, would include recording blood pressure and other vital signs, indicating the clinical reason for checking blood pressure (i.e., follow up to previous abnormal finding, symptoms suggestive of abnormal blood pressure, etc.), and listing any current medications with an indication of the patient's compliance in taking them.

Also, if you're billing the 99211 service as an incident to service (instead of being provided by the billing physician or nonphysician practitioner), you need to have an indication of the supervising provider's evaluation of the clinical information obtained and his management recommendation.

Good advice: "You could certainly use 99211 when it's appropriate over waiving the charge, which I've seen happen before," says Cindy Foley, billing manager for three ob-gyn practices in Syracuse, N.Y. "Regardless of why the patient is in the office, she's here to use our expertise and services, and that's a legitimate charge we coders should bill. Sometimes the reimbursement is little more than the copay, but that's not the point. We need to charge for our time, every time."

Example: On the other hand, suppose a patient phones your office and reports that she misplaced the dressing material the doctor had provided. She also reports that all her BP readings at home for the last week were normal.

She returns to your office with her readings. The nurse hands the patient new dressings, takes the readings, and puts them into the patient's record.

Solution: Because the nurse simply hands her the new material and accepts the readings, you should not report 99211.

The new patient E/M codes do  not offer an equivalent to 99211. Registered nurses cannot report 99201, the lowest-level new patient office visit code. Physicians must see new patients. Nurses cannot see established patients who have new problems. The physician or NPP must firsttreat the patient for the problem, before you can report 99211. "It's the rule," Foley says.