Pediatric Coding Alert

Question: I’ve been coding all nurse visits with 99211, but I’m being told that’s not correct for new patients. How do I report when a new patient sees a nurse rather than a physician if not with 99211?

New York Subscriber

Answer: Because 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) does not require the presence of a physician and requires no history, exam, or medical decision making (MDM), it’s common to assume you can use the code for a new patient who receives office/outpatient evaluation and management (E/M) services from a nurse practitioner, (NP), a physician assistant (PA), or any other nonphysician practitioner (NPP). However, this is not the case.

Here’s why: First, the CPT^® code descriptor for 99211 describes the service as being for an established patient, so it cannot be used for a new patient.

Second, the code can only be for established patients because if the service is provided by someone other than a physician or other qualified healthcare professional (QHP), the service will still be reported under the supervising physician or QHP’s provider number. Medicare regards this service as incident-to the physician, and you cannot provide incident-to services to a new patient because one of the many requirements for incident-to reporting is that there must be a course of treatment in place, which cannot be true for a new patient.

Lastly, QHPs, including NPPs, are eligible to report any appropriate level of E/M service. Thus, if a QHP sees a new patient, that encounter may be reported with 99202 (Office or other outpatient visit for the evaluation and management of a new patient… straightforward medical decision making…) at a minimum, which is not only more appropriate coding but also pays better than established patient code 99211.