Primary Care Coding Alert

Proper use of low-level office visit codes (99201 and 99211) can provide an important stream of revenue for family practices, according to 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. However, many practices misuse these codes and may incur penalties.

99211 Reported More Frequently

Established patient code 99211 is assigned more frequently than the corresponding new patient CPT 99201 and is often referred to as a nurse visit. This is a basic level of service that doesnt require the presence of a physician or nonphysician practitioner [NPP], Wiggs explains. Care is usually provided by a registered nurse, licensed practical nurse or certified medical assistant. It may be assigned when:

diabetic patient comes in for a glucose check,
patient comes in to have sutures removed,
newborn is brought in for a weight check,
child is brought in for peak-flow meter instruction, or
postsurgical patient needs his or her dressings changed.

Unlike other office visit E/M codes, 99211 has no documentation requirements for history, physical exam or medical decision-making, Wiggs points out. However, the nurse must be face-to-face with the patient, and must record the visit in the chart. These notes should include the date, the reason for the patients visit, the service provided per the doctors order and the nurses signature.

A typical visit might occur if an established patient comes in because of a minor sore throat. The nurse conducts a nursing assessment and performs a rapid strep test, which is negative. The patient then leaves without seeing a physician.

Virtually all 99211 visits are billed as incident to services under the physicians (or NPPs) name and provider identification number, and must follow the appropriate guidelines.

When 99211 is reported for a follow-up visit with a patient who has an existing condition, family practices must consider two specific requirements, Wiggs says. First, the physician or nonphysician practitioner must have originally established a treatment plan and dictated the medical necessity of having the patient follow-up with the nurse. Secondly, the nurse must be under the direct supervision of the physician or NPP. Although they do not need to be in the exam room, they must be physically present in the office or clinic. Availability by phone does not meet the requirement.

When Not to Report 99211

Excessive reporting of 99211 has been the cause of Medicare fraud investigations, and practices must ensure they are using the code correctly. It is easy to assign this code for services that are clearly not covered, Wiggs says. Examples include:

1) Telephone calls. Frequently, practices will talk to patients by phone to discuss prescription refills, test results or diagnoses, or to explain specific aspects of care. These, however, should be billed with codes 99371-99373 (Case Management Services, telephone calls);

2) Non face-to-face time spent reviewing records and tests, arranging for further services or communicating with other professionals through written reports or telephone contacts;

3) Completion of forms like home health or durable equipment certification;

4) Patient delivery of a laboratory specimen to the office for a follow-up on a previous complaint or diagnosis and no other service is provided at that time; and

5) Services to homebound patients.

Wiggs also points out that 99211 should not be reported when a patient is seen in the office simply for an injection or to draw blood. The services provided by the nurse or medical technician are included in the procedure charge (i.e., 95115, professional services for allergen immunotherapy not including provision of allergen extracts; single injection). However, the nurse evaluation for the earlier example of sore throat and possible strep is not included in the specimen charge of a rapid strep test.

Note: A sample policy developed by Wiggs is included on this months insert (Sample 99211 Policy A).

Some Practices Limit Use of 99211

Although allowed, some practices choose not to assign 99211 even when it is appropriate as a public relations gesture to patients. According to Sue Foster, business office manager for Buffalo Clinic, a 31-physician multi-specialty practice in Buffalo, Minn., her family physicians have decided not to bill 99211 for specific services, including blood pressure checks or reading TB skin tests.

Note: Fosters practices policy is reproduced on the enclosed insert (Sample 99211 Policy B).

We understand that this is a very conservative approach and that we may be losing a small amount of revenue, she says. But our physicians made this decision for the benefit of our patients. Many of our patients are used to coming here for some of these services without charge. If we begin to submit claims for 99211, they will be charged a co-pay.

Dont Report Both 99211 and Additional E/M Codes

Sometimes an appointment that began as a nurse visit escalates. Perhaps the patients blood pressure is significantly elevated or the nurse observes a possible infection when changing a dressing. Instances like these demand a physicians attention.

If there has been a significant change, the physician will want to see the patient, Wiggs says. This encounter will probably then include a physical exam, history and increased medical decision-making. These components will justify assigning a higher-level E/M code perhaps a 99212 or 99213. You would report only this code and not the 99211, which was originally scheduled.

99201 Used In Limited Situations

Although not reported as often, 99201 is used to report limited new patient encounters. Because the patient has not been seen before, the physician or NPP must provide the care, and document a problem-focused history, problem-focused exam and straightforward medical decision-making. This is rare because, even if no major problem prompted the visit, the physician will probably conduct a thorough exam and history which would represent a higher-level E/M service.

Foster says her practice reports 99201 most often through its urgent-care services. During non-office hours, we will get a fair number of new patients who present with very limited problems. One typical example is a child being seen for strep throat. The visit is focused on that problem, and the strep test provides direction for a simple treatment decision.