Pediatric Coding Alert

Question: A patient presented for a visit but the pediatrician failed to complete the office note, leaving his portion completely blank, although the nurse completed her portion. When asked about the visit after the fact, the pediatrician did not remember the details of the visit. Can we report just the nurse’s portion of the visit with 99211, or should we not bill the claim at all?

Answer: You can report 99211 based on the nurse’s documentation. 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®.