Pediatric Coding Alert

Hint: The 'nurse visit' code isn't just for nurses.

Insurers know that 99211 is frequently misused making it a target on audits. Protect your practice from 99211 payback requests by addressing these 'nurse visit' code myths.

Who Can Use 99211?

Myth: You should use 99211 only for nurse visits.

Fact: Physicians, nurse practitioners, and physician assistants can use 99211 as well as nurses. The level of history, however, associated with 99211 often means that when a healthcare professional provides the service, the components that are medically necessary to be performed will often be higher than 99211.

What Does 99211 Require?

Myth: You should automatically use 99211 to bill for allergy shots and vaccinations if the provider did not provide any other service.

Fact: You can't report 99211 for just an allergy shot or vaccination. To bill 99211, the patient must have a problem that requires a nurse assessment. Documentation must indicate the concern, such as a missed injection or minor reaction, to bill 99211 in addition to 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) or 95117 (... 2 or more injections). A cold or rash might be a reason that a nurse assessment is medically necessary before administering a previously scheduled vaccination.

Do Private Payers Follow Incident-to Policies?

Myth: Incident-to rules don't apply to 99211.

Fact: The incident-to rules do apply to 99211, in order for a physician to bill for the services of a nurse or non-physician practitioner. If a non-physician bills under the billing physician's name using 99211, follow the payers' incident-to regulations. Incident to is a Medicare policy, but many private payers have some requirements for reporting services that qualified staff perform and report under the physician's national provider identifier (NPI).

Medicare incident-to rules require that the person performing the service be an employee or contractor of the billing physician or group under which you're billing the service. Also, the service must be in the physician's office, and the physician must be immediately available in the building. The physician must have prescribed the service, and the patient must be an established patient with an established problem.

What Levels Can a Nurse Report?

Myth: Nurses can bill for all levels of E/M visits as long as the physician is in the suite.

Fact: Physicians can bill for the services of nurses only using 99211 under the incident-to regulations. Under incident to, physicians can bill for the services of nurse practitioners and physician assistants for all levels of E/M services.