Primary Care Coding Alert

Your nurse visits will withstand scrutiny safeguarding almost $20 per claim.

With incident-to services on insurers- radar, you-ve got to ensure documentation supports your 99211 claims to avoid facing huge paybacks.

Code 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of the physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) pays approximately $18.75 (0.52 relative value units on the 2009 Medicare Physician Fee Schedule) per encounter.

To see if your 99211 charges will stand up on review, take this quiz.

Patient, Diagnosis Are Established

Question 1: A new patient comes in for a blood pressure check, which a licensed practicing nurse (LPN) takes. Is there a CPT nurse visit code for a new patient?

Answer 1: -It would not be appropriate to report a nursing service E/M (99211) for a new patient,- says Irene Quast, CPC, CEMC, with Brown Consulting Associates, Inc. in Twin Falls, Idaho.

The medically necessary service must be for an established patient with an established diagnosis and appropriately documented to meet Medicare's and other payers- incident-to rules. Absent a previous encounter with the physician for the diagnosis in question, there is nothing to which the service is otherwise incidental.
 
Encounter Involves Direct Patient Contact

Question 2: A patient comes in to drop off a urine sample to make sure her recurrent urine tract infection (UTI) has resolved. Does the dropoff warrant reporting 99211?

Answer 2: You should not use 99211 when clinical staff does not provide direct face-to-face contact with the patient. The face-to-face provider must be an employee, contractor or leased employee operating under direct supervision (meaning a supervising physician or nonphysician provider is in the office suite) with an order for the service and the ordering physician/practitioner identified. Documentation should include some E/M of the patient's condition, not just receipt of a specimen. 

But suppose the physician had written an order for the patient to drop off a sample after two weeks of antibiotic treatment and for a nurse to check for any remaining symptoms. The patient still complains of pain on urination, and the nurse confers with the physician who recommends a continued course of antibiotic.

-99211 can be used for a medication refill if the physician/practitioner is providing ongoing management for the patient,- says Quinten A. Buechner, MS, MDiv, CPC, ACS-FP/GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

No Procedure Code Describes Service

Question 3. An established patient comes in for a blood draw. Should you report the service as 99211?

Answer 3: Do not use 99211 when another code describes the service, Buechner says.

Reason: CPT states: -Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided.- 

You would instead bill the applicable code, which in this case would be 36415 (Collection of venous blood by venipuncture) for the blood draw.

Service Is Medically Necessary

Question 4: Suppose a patient presents for a flu shot and also complains of a cough and congestion. Under office protocol, the nurse assesses the patient's complaints, determines administering the vaccine presents no contraindications, and goes ahead with administration. Would 99211 be appropriate in this instance?

Answer 4: Yes, because the nurse, under a physician's orders, performs a medically necessary E/M to evaluate the patient's chief complaint before administering the shot, you can bill 99211-25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Watch out: Buechner cautions the nurse must document the rationale for medical necessity, and that the E/M that supports the service.