Pediatric Coding Alert

Knowing when to report CPT 99211 can confound the most experienced pediatric practices but asking three key questions should solve the 99211 puzzle.

Code 99211 continues to be a source of confusion and debate for many coders as evidenced by frequent reader questions, such as "Requirements of 99211," Pediatric Coding Alert, August 2002.

Remember that 99211 usually triggers a copayment, and families should be made aware of this. In addition, the code is for established patients only 99211 (Established patient office visit usually the presenting problems are minimal).

"99211 is often called a nurse visit," says Catherine Brink, CMM, CPC, president of Health Care Resource Management Inc., in Spring Lake, N.J. It is the lowest-level E/M visit for an established patient and is typically used when the nurse sees a patient for a minor problem.

Although physicians and nonphysician practitioners, such as nurse practitioners and physician assistants, are not barred from using 99211, they will use a higher-level E/M code in most cases because of the greater complexity of care they usually provide.

Many coders don't realize that 99211 can be used by office employees other than the nurse, says Kathy Pride, CPC, CCS-P, HIM applications specialist with the San Rafael, Calif.-based QuadraMed. Any qualified "auxiliary personnel" who are employees of the physician, such as medical assistants, licensed practical nurses, technicians and other aides, and are working under the physician's direct supervision can provide services to patients under the "incident-to" umbrella using 99211, as long as the visit meets the "medical-necessity" requirement for billing an E/M code, she says. The physician must be present in the office when the service is performed, and the auxiliary personnel must be qualified to perform the service.

Note: For more on auxiliary personnel, read Section 2050.1 of the Medicare Carriers Manual.

Coders frequently question whether they can use 99211 when a patient comes to the office for common procedures, such as lab work.

The first question the coder should ask is: Does the service that was provided have its own CPT code?

"If the service has an identifiable code, you bill that code," Pride says.

For example, a patient comes to the office for a urinalysis as part of routine lab work scheduled a week before a regular checkup. Use CPT code 81002 (Urinalysis, by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy).

You cannot code 99211 for the time that the nurse or assistant spends with the patient unless another medically necessary service is provided in addition to the lab work. For example, say the routine urinalysis indicates a urinary tract infection. The nurse must then discuss the findings with the doctor, who decides he doesn't need to see the patient before the annual exam the following week but will write a prescription for an antibiotic to be started in the interim. The criteria for medical necessity have been met, and 99211 can be coded in addition to 81002, with diagnosis code 599.0 (Urinary tract infection, site not specified).

If the service provided to the patient by auxiliary personnel does not have an identifiable CPT code of its own, you may be able to use 99211. Because 99211 does not have required elements of history, examination and decision-making, many pediatric offices are unsure when and how to use the code. The key is to establish the same medical necessity that is required for all E/M codes. "Make sure you document what service was performed and the medical necessity for it," Pride says.

Another frequent question is whether offices can assign 99211 for a prescription refill.

"Did the doctor write out the prescription and leave it at the front desk for the patient to pick up?" Pride asks. If the answer is yes and the patient simply picked up the prescription and left, the refill cannot be billed.

However, if there is a medical reason for the nurse or other office personnel to evaluate the patient when he comes in to pick up the prescription, use 99211. For example, a doctor recently changed allergy medications and wants the nurse to evaluate the effect on the patient before giving him a three-month prescription of the medicine. Or, the pediatrician recently prescribed Ritalin to a patient who has attention deficit disorder. The nurse evaluates the child's response to the medication, possible side effects and consults the pediatrician for appropriate dosage adjustments.

Coders often disagree about whether to use the nurse visit code (99211) in conjunction with the immunization administration codes (90471-90472) and the vaccines/ toxoids codes (90476-90749) for immunization-only visits. CPT's introduction to the vaccines/toxoids section clearly states that 90476-90748 "identify the vaccine product only" and that immunization administration code(s) 90471, 90472 must be reported in addition to the vaccine code. The section further instructs that if a significantly, separately identifiable E/M service is performed, "the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration codes."

CPT Assistant November 1999 offers the following example: A nurse under the physician's supervision reviews the patient's chart, takes the child's blood pressure and temperature, provides vaccine information, instructions and consent forms to the parent, and prepares the vaccine product prior to the administration of the vaccine. The office or other outpatient evaluation and management code 99211 may be reported in addition to the administration (90471, 90472) and appropriate vaccine product code (90476-90749), according to the article.

Document these services and the medical necessity for the nurse's actions to support billing 99211.