Pediatric Coding Alert

Hint: You can't automatically tack 99211 on to every service just because the nurse was present.

Most pediatric practices agree that 99211 is a ubiquitous code, reported nearly every day for visits ranging from blood pressure checks to medication updates. But the so-called "nurse visit" code may not always be appropriate. Many payers are scrutinizing these claims and targeting them as "areas of concern." Check out these common clinical scenarios and determine whether 99211 is appropriate for the circumstances.

Will 99211 Cover Vaccines?

Question 1: A patient presents for vaccines only. The nurse administers two vaccines and the patient leaves. Should you report 99211 with the vaccine administration codes?

Answer 1: Not as a rule, no. If the nurse simply administers a vaccine and the patient leaves, the nurse most likely has not met the medical necessity E/M criteria for billing 99211. If, however, the nurse spends a lot of time counseling the patient or the patient has other diagnoses that the nurse goes over, then 99211 might be appropriate.

In this case, if a medically necessary E/M services is provided by the nurse, you will need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99211. However, documentation of a vaccine alone would not allow you to meet the requirements of 99211.

Example: A patient presents to the nurse for a vaccination, but the mother explains that the child has had a rash for two days. The nurse examines the rash and determines that it won't interfere with the vaccination. The nurse documents the examination of the rash in a separate E/M note from her vaccine documentation. In this situation, you can link 99211 to the rash diagnosis (with modifier 25 appended), and report the vaccination separately.

Know Whether 99211 Applies to X-Rays

Question 2: A 13-year-old patient comes to see the pediatrician for leg pain after getting injured during a football game. The staff performs x-rays and then the patient waits in the exam room for the pediatrician, but the patient's mother gets a call and she and her son have to leave before actually seeing the physician. Does 99211 apply to this visit?

Answer 2: "What is unanswered is was the x-ray ordered by the doctor?" asks Ruby Woodward, BSN, ACS-OR, coding and research specialist in St. Louis Park, Minn. "If the physician ordered and read it, bill the x-ray unmodified. If the physician did not order the x-ray, then nothing can be billed."

In short, Woodward says, you cannot report 99211 unless an actual face-to-face evaluation and management service was provided.

Can You Downcode to 99211 for Incomplete Physician Notes?

Question 3: A patient presents for a visit but the physician fails to complete the office note, leaving his portion completely blank, although the nurse completes her portion. When asked about the visit after the fact, the physician does not remember the details of the visit. Can you report just the nurse's portion of the visit with 99211, or should you not bill the claim at all?

Answer 3: You can report 99211 based on the nurse's documentation, says Michelle McDonald, CPMA, CPC, a coder-educator in the Medicare Risk Adjustment Department at Humana, Inc.

"It is important to document the fact that the visit was actually done on the date of service it occurred and

ideally if the staff is proficient in this case, will also document the fact that the patient was seen by the doctor but no documentation was made specifically by the physician so it was not billed as a 'physician face to face' visit per guidelines set forth in CPT®," McDonald　adds.

Is Face-to-Face Required?

Question 4: A mother and her daughter come in to drop off a urine sample to make sure the daughter's recurrent urine tract infection (UTI) has resolved. Does the dropoff warrant reporting 99211?

Answer 4: You should not use 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 nonphysician provider is in the office suite) with an order for the service and the ordering physician/practitioner identified. Documentation must include some E/M of the patient's condition, not just receipt of a specimen.