Primary Care Coding Alert

Learn 99211's 3-fold requirements

You can bill a nurse visit with confidence as long as you apply the code only when the nurse provides a service that is medically necessary to an established patient.
 
Coding experts recommend that you report 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problems are minimal. Typically, 5 minutes are spent performing or supervising these services) if the service meets these three criteria:

1. Staff Perform an E/M

To report the lowest-level established patient office visit code, a nurse must perform an evaluation and management service. Don't use 99211 simply to get a service paid, says Quinten A. Buechner, MS, MDiv, CPC, CHCO, president of ProActive Consultants LLC in Cumberland, Wis. You should use 99211 when documentation indicates auxiliary staff provided an E/M service.
 
Look for notes such as "Skin looks fine," "Blood pressure is normal," or "Condition controlled with medication." Documentation that includes a chief complaint or history also indicates that the nurse performed a service, says Jaime Darling, CPC, certified coder for Graybill Medical Group, which has nine family physicians, in Escondido, Calif.

2. The Service Is Medically Necessary

Only performing a blood pressure (BP) check doesn't warrant 99211 - the service must also be medically necessary.
 
Consider two BP scenarios. A 30-year-old comes in and requests a BP check because he thinks his blood pressure is high. In this case, you shouldn't use 99211, Buechner says. "No medical reason exists for performing the service."
 
But suppose your family physician tells a 60-year-old female patient with hypertension (such as 401.1, Essential hypertension; benign) to return to his office every six months for a BP check. This situation calls for 99211, Buechner says. The check is medically necessary to keep track of the patient's hypertension.

3. The Patient Is an Established Patient

You may report 99211 only for an established patient. Code 99211 is CPT's way of offering incident-to," Buechner says. The code represents a relatively simple delegated service that staff perform under a physician's supervision. 

Any employee who is qualified to perform the service may report 99211 incident-to your FP. The physician must authorize, supervise (be present in the office suite) and sign off on the E/M service, Buechner adds.