Primary Care Coding Alert

Policy Name: Coding and Documenting 99211 Office Visits

Policy Number: 101

Effective Date of Policy: January 2001

Purpose of Policy:

The purpose of this policy is to clarify the use of the established patient evaluation and management CPT code 99211. According to the 2001 CPT manual, 99211 is an 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 problem (s) are minimal. Typically, 5 minutes are spent performing or supervising these services.

Procedures:

1. Physicians, nurse practitioners, physician assistants would rarely use CPT code 99211. All nursing staff (RNs, LPNs, CMAs) are eligible to use the 99211 code. Services provided by RNs, LPNs and CMAs must be those that fall under the scope of care as stated by their individual licensing requirements.

2. The physician, nurse practitioner, physician assistant must be actively treating the patient. Within the treatment plan the physician, nurse practitioner, physician assistant must dictate the medical necessity of having the patient follow-up with the nurse, for instance, suture removal, dressing changes, newborn weight check and peak-flow meter instruction.

3. Unlike the rest of the office visit codes, 99211 does not have any documentation requirements for history, physical exam or medical decision-making. The nature of the presenting problem need be only minimal. The nurse must be face-to-face with the patient. At a bare minimum, the nurse must record the date, reason the patient presented, the service provided (always adding as per doctors order), vital signs, and their signature in the patients chart.

4. The nurse must complete the superbill, checking the established 99211 code, and circle the appropriate ICD-9 code. Submit the superbill per the clinics routine.

5. The practice manager or office coordinator is responsible for orienting the appropriate appointment/check-in desk personnel to this policy.

6. A 99211 should not be billed when the sole intent of the patient visit is the injection of a vaccine.

7. Per Medicare guidelines, a physician must be present in the office or clinic where the nurse services are being rendered when code 99211 is billed as incident to.

8. Code 99211 shall not be billed for the following:

A. Non face-to-face time, such as reviewing records and tests, arranging for further services and/or communicating further with other professionals and the patient through written reports or telephone contacts.

B. For the completion of forms such as home health or durable equipment certification.

C. When the patient has been instructed to leave a laboratory specimen at the office for a follow-up on a previous complaint or diagnosis and no other service is provided at that time.

D. For an employees services to homebound patients.

E. For foot care services that have other appropriate CPT and HCPCS codes available.

F. Giving patient orders over the phone, calling in a prescription refill to the pharmacy, calling a patient to reschedule a procedure, faxing medical records to a hospital, recording lab results in a patients chart and/or calling to inform patient of lab results.


Sample policy provided by Debra Wiggs, CMPE, chief executive officer of Community Physicians Administrative Support Services, LCC (ComPASS), a billing and collections firm that provides support to 45 primary care practices in Washington state.