Pediatric Coding Alert

Find out who should provide the service, and how and when it should be documented.

Of all the outpatient evaluation and management (E/M) codes, none is more misunderstood than 99211 (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).

So says Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America. The problem is that “the description says, ‘may not require the presence of a physician,’ so it usually winds up being used when the physician is not immediately available. So, we need to watch how it is used,” Hauptman cautions.

That’s why coders always have so many questions about how to use 99211. Here are four of the most frequently asked, along with some expert answers to help you sort fact from fiction.

Question: Should I report 99211 when a physician or NPP provides the service?

Answer: “Code 99211 is used when nurses see patients for discussions or quick follow-ups at the request of the physician. Whoever administers the service does such things as take vitals and blood pressure with the right diagnosis,” Hauptman reminds coders.

So, while physicians and nonphysician practitioners (NPPs) can technically perform 99211 services, it’s not a good idea for them to do so. “If it is necessary for a patient to see a physician or NPP, you should at least document a 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) or a procedure code for the medical necessity of the visit,” says Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB,  owner/consultant of Professional Coding Solutions in Holcombe, Wisconsin.

Question: Who is responsible for documenting 99211 if it is supervised?

Answer: “One of the most common mistakes I find with 99211, especially for Medicare patients, is that there must be a physician-documented request that the patient be seen for some kind of follow-up with staff personnel,” says Rasmussen. “The request could be in the form of a statement in a patient encounter such as ‘follow up with x in one week for a blood pressure check,’ or it could be in the form of a formal order, but it must be somewhere.”

More, “the service documented must be medically necessary. I like to see the nurse/personnel seeing the patient for a 99211 document the request and by whom, the medical necessity of the service, and what occurred during the service,” Rasmussen adds.

Question: Can I use 99211 for vaccine administration?

Answer: CPT^® guidelines direct you to “select the name of the procedure or service that accurately identifies the service performed” and “not select a CPT^® code that merely approximates the service provided.” This means that “99211 must never be reported when there is a more specific documented service with its own code,” according to Rasmussen.

For example, “coumadin checks have their own code, while venipunctures should be billed instead of a 99211 and allergy shots are also usually billed with an administration code,” according to Hauptman. So, you should apply the following codes rather than 99211 when appropriate:

• 36400–36410 — Venipuncture, age 3 years or older, necessitating the skill of a physician or other qualified health care professional …
• 36415 — Collection of venous blood by venipuncture 
• 36416 — Collection of capillary blood specimen (eg, finger, heel, ear stick)
• 36420–36435 — Venipuncture, cutdown …
• 90460–+90461 –– Immunization administration through 18 years of age … with counseling by physician or other qualified health care profes­sional …
• 90471–+90474 –– Immunization administration …
• 93793––Anticoagulant management for a patient taking warfarin …
• 95115–95117 –– Professional services for allergen immunotherapy not including provision of allergenic extracts …
• 95120–95125 –– Professional services for allergen immunotherapy … including provision of allergenic extracts …
• 95131–95134 –– Professional services for allergen immunotherapy … including provision of allergenic extracts … stinging insect venom.

Coding caution 1: Never use 36400-36410 and 90460-+90461 when a member of your clinical staff administers an immunization. That’s because the counseling that goes along with immunization has to be administered by a physician or QHP, as the code’s descriptor stipulates.

Coding caution 2: The CPT^® guidelines that accompany 90460-+90461 and 90471-+90474 also note that you should only report 99211, or any of the 99201-99215 E/M codes for that matter, “if a significant separately identifiable E/M service is performed.” So, in an encounter where a patient returns after having previously canceled an immunization due to illness, and a nurse examines that patient to make sure the patient is now well enough to receive the vaccine, you would be able to document 99211 in addition to the vaccination administration using 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).

Question: Can I use 99211 when patients drop off specimen samples or paperwork, or pick up a prescription?

Answer: If the patient is just dropping things off to, or picking things up from, your front desk, the answer is “no.” However, if the patient has a face-to-face meeting with your pediatrician, a qualified healthcare provider (QHP) such as a physician assistant (PA), a nurse practitioner (NP), or a member of your clinical staff in order to review side effects of a prescribed medication or how it should be taken, that would justify documenting 99211. Simply put, the encounter should be face-to-face, and it should be for the “evaluation and management” of the patient as the code descriptor says.