Podiatry Coding & Billing Alert

Hint: Only report 99211 for established patients.

In some cases, an established patient may visit your office to see a provider other than the podiatrist, like a nurse practitioner. If the visit warrants a minimal evaluation and management (E/M) service based upon the documentation and medical necessity, you may be able to bill a 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).

Learn how to ethically report this often misunderstood code in your podiatry practice.

Myth #1: Only Nurses Can Report 99211

Truth: Although it’s sometimes referred to as the “nurse visit” code, 99221 isn’t just for nurses. Any qualified auxiliary personnel the physician employs can report 99211 — including the physician. This includes medical assistants (MAs), licensed practical nurses (LPNs), technicians, and other aides who work directly under the physician’s supervision.

“It’s still appropriate for a physician or nurse practitioner to use the 99211 if that’s all that their documentation and medical necessity actuallymeets,” says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla., “So, [99211] is not just a nurse E/M service.”

Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, N.M. echoes Mac’s thoughts about who can report 99211.

“While we usually refer to 99211 as a ‘nurse only’ visit, there are times when a billing provider has only documented this level of service (rather than, say a 99212) if that provider did notperform an exam or take a history and only documented medical decision making (for example),” Witt says.

Myth #2: You Can Report 99211 for New Patients

Truth: You should report 99211 for established patients only — never new patients.

“Use of 99211 is strictly for established patients — never a new patient since there must be a plan of care with the plan documenting a brief follow-up E/M encounter,” says Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, N.J. “This follow-up E/M can be performed incident-to, meaning not requiring a physician to perform the service.”

Shannon O. DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, partner at DoctorsManagement, and president of NAMAS in Melbourne, Fla., agrees that 99211 must only be used for established patients.

“99211 is only for established patient’s because it is technically performed incident-to, meaning the ancillary staff nurse will be using the supervising provider’s billing information to get the practice paid for the work,” says DeConda. “In order to meet the guidelines associated with incident-to, the patient must have a plan of care that has already been created by a supervising provider. The nurse would be providing following services directly indicated and/or appropriate to the plan of care.”

Official definition: CPT^® defines an established patient as one who has received professional (face-to-face) services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past 36 months (three years).

Myth #3: Incident-to Rules Don’t Apply to 99211

Truth: You should always apply incident-to rules in regards to 99211 services.

Incident-to, in relation to the 99211 service, according to Mac, means that a provider (the nurse practitioner, PA, physician, etc.) previously saw a patient, and the patient is returning for a specific service based upon the treatment plan developed that previous visit.

When the patient returns to the office for the specific service, the physician must be immediately available within the office. Although the physician doesn’t have to see the patient, the physician must be present in the office suite to provide the required supervision. This is referred to as direct supervision, Mac says.

Important: If the same physician who provided the original order is not the supervising physician during the patient’s return visit, the service must be billed under the physician who is supervising the day that the patient returns. So, the physician could be different, according to Mac.

Coding solution: Look to this example from Dr. Arnold Beresh, DPM, CPC, CSFAC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va. on how to properly report a 99211: The patient returns to the office 13 days after a permanent toenail removal of the left first toe (11750). The patient complains of mild pain, no drainage, and some redness of the toe. The provider (perhaps the nurse) documents and examines the patient and notes that he has mild erythema, but he has no other signs ofinfection. The patient is instructed to continue to clean the toe with soap and water and apply Neosporin for three more days. There is no follow-up appointment made. The provider must report all of this information to the physician. So, although the physician doesn’t have to see the patient, he must receive that information about the encounter from the provider. The 99211 could then be billed under the physician who provided the supervision and was in the office that day.