Primary Care Coding Alert

Hint: Descriptors and documentation are your best guides.

Of all the evaluation and management (E/M) codes, 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.) may be the most misunderstood.

Known informally as the “nurse’s code,” so-called because licensed practical nurses (LPNs), medical assistants, and other clinical staff supervised by a physician can administer the service, 99211 has produced a number of myths that have continued to plague coders since the code’s introduction in 1992.

Help’s here: So, we’ve gathered four of these 99211 myths together and attempted to debunk them for you once and for all.

Myth 1: You Can Use 99211 to Code for Vaccine Administration

The introduction to the CPT^® contains the following instructions:

• “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.”

“Code 99211 describes an office or outpatient visit and does not identify immunization/vaccine administration,” Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians, reminds coders. “There are other codes for immunization/vaccine administration — 90460-+90461 [Immunization administration through 18 years of age … with counseling by physician or other qualified health care professional …] if counseling accompanies the administration and 90471-+90474 [Immunization administration …] if it does not — and they should be used to report that service,” Moore adds.

The CPT^® guidelines that accompany 90460-+90461 and 90471-+90474 also note that you should only report 99211, or any of the 99201-99215 E/M codes for that matter, “if a significant separately identifiable Evaluation and Management service is performed.” So, “if a patient originally presented for a vaccine, but didn’t get it due to a fever, a nurse visit would be appropriate to assess the patient being well enough now — with no fever — to get the vaccine,” says Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

In this case, you could document 99211 in addition to the vaccination administration using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

Remember: “The 99211 code will cause a copay, which the regular vaccine administration codes [90471-+90474] will not,” Holle reminds coders.

Myth 2: Physician Documentation Is Necessary When You Code 99211

The confusion here lies in the code’s descriptor, which states that the service should be performed or supervised.

Supervision in this sense does not mean that a physician has to document the service. In reality, “it means that the physician has to be present in the office as the visit is still, technically speaking, incident-to the physician’s services, meaning that the staff member administering the care should be following a plan already established by a supervising provider,” Holle explains. “So, if the assessment requires more than the nurse can take care of, the physician takes over the visit, and no 99211 is billed.”

In the end, however, the person who performs the service is responsible for, and should complete, the documentation. Additionally, if 99211 is performed and billed, your staff member should also document that the services provided are related to services that your physician has already provided to the patient.

Myth 3: 99211 Services Don’t Have to Be Face-to-Face

It might be tempting to use 99211 for encounters with patients seeking to simply drop off paperwork or a specimen sample. However, “99211 is generally understood to be a face-to-face service that involves evaluating a patient and managing the patient’s condition,” Moore notes.

Consequently, it’s good practice to document the reason for the visit, a history of the patient’s illness, details of any exam, and a brief evaluative statement of the encounter, just as a provider would for any other level of E/M service. In some cases, even a prescription refill could rise to the level of 99211 if the staff member providing the service documents counseling the patient on the medication’s side effects and/or the correct way to take it.

But face-to-face does not necessarily mean the patient has to be physically present at the time of the service. “Code 99211 is on Medicare’s list of telehealth services, and some payers may allow it to be provided virtually via use of interactive audio and video equipment,” Moore explains. “But even in that instance, the service is still, in a sense, ‘face-to-face’ even if it’s not ‘in person.’”

Myth 4: You Can Use 99211 for New Patients

This is a myth for two very good reasons. First, “CPT^® describes the [99211] service as being for an established patient, so it cannot be used for a new patient,” Holle explains.

Second, the code can only be for established patients because, as previously mentioned, the service is performed incident-to. Because of that, it follows that the patient must already be established with the practice and have had at least one prior appointment where the supervising provider initiated a care plan.