Primary Care Coding Alert

Nugget: To properly use 99211, the nurse must know when to involve the physician, or the practice may not be able to bill for the additional services.

Nurse-conducted evaluations of patients for routine follow-up visits or other minor services are common occurrences in family practices. Nonetheless, some clinicians are concerned about billing for a visit when the doctor doesnt actually see the patient.

Family practice coders should recognize that it is appropriate to charge for nurse-only visits when the visit meets carrier requirements. Typically, the most accurate way to bill for a short nurse-only visit is to use 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician).

For a nurse-only visit, the presenting problems are typically minimal and the normal visit time is only five minutes or so, says Mary Mulholland, BSN, RN, CPC, reimbursement analyst in the Department of Medicine at the Hospital of the University of Pennsylvania in Philadelphia. There are no specific time restraints placed on 99211, she adds, but five-minutes is recognized as the rule of thumb. The actual time spent with the patient may vary according to the needs of the patient. There is no need for a nurse to rush through this type of visit.

Mulholland notes that the nurse might render a range of services including, but not limited to:

vital sign checks;

uncomplicated suture removal, if placed by another physician;

dressing changes;

diet instructions;

review of self-medication administration, including a discussion of possible medication side effects;

rapid strep screening test; and

formal patient education instruction.

For instance, a family practitioner may treat an elderly patient for rheumatoid arthritis (714.0). The patient will likely experience decreased range of motion and some limitation in their activity level. A nurse might review energy conservation methods with the patient to help them perform activities of daily living more efficiently, explains Mulholland.

A nurse also may see a patient who is being monitored following an adjustment of a medication. Perhaps the physician has ordered a lower medication dosage for a patient who suffers from hypothyroidism (244.9). The lab tech would draw the blood and run the lab tests, points out Marilee Phillips, RN, nurse specialist at the offices of David Neustadt, MD, in Louisville, Ky., but I may be called in to answer patients questions, which can be time-consuming. For that, we bill the 99211.

In a case like this, the nurse may also check the patients vital signs and question the patient about any potentially worrisome symptoms such as heart palpitations, weight gain or tiredness.

When the Nurse Notices a Change in Condition

Mulholland says that 99211 is not intended to be a comprehensive evaluation and management (E/M) visit by a nurse. If fact, if the visit is extending much beyond the suggested five minutes, perhaps it is better suited for a physician. There are no modifiers for extra time for the 99211 because anything that takes much longer than the normal five minutes or so is more complex than a registered nurse should be performing, she says.

Technically, CPT does not prohibit the use of the prolonged service codes 99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g,. prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service]) and 99355 (each additional 30 minutes [list separately in addition to code for prolonged physician service]) for nurse visits. But Mulhollands point is accurate nurses who encounter problems requiring prolonged care should include the physician.

For example, a patient who was treated for an inch-long laceration of the foot (892.0, open wound of foot except toe[s] alone without mention of complication) may come in to have sutures removed. But the nurse notices that the wound appears to have become badly infected. At that point, the nurse should bring in the doctor.

When the nurse, in the course of evaluating the patient, discovers an abnormality, a new problem or an exacerbation of an existing problem, he or she must notify the supervising physician, says Mulholland. The nurse can not be the one to determine what the problem might be or decide what future course of action to take.

Once the nurse alerts the physician to the patients new symptoms, the physician most likely would want to see the patient right away. If the physician subsequently provides an E/M service for this patient on the same date of service, then only the physicians service would be reported, says Mulholland. The claim form must contain the medical necessity for the physicians services as demonstrated by the use of the appropriate ICD-9 diagnosis. No modifiers are necessary, since the ICD-9 codes will identify the conditions treated during the visit.

For example, the doctor would report the visit with the patient described above by using an established patient E/M code (99212-99215) with the diagnosis code for the foot wound and infection (958.3, posttraumatic wound infection, not elsewhere classified). The 99211 would not be billed.

Another typical situation may occur when patients suspect they have contracted strep throat, especially parents who want to have a child checked before sending them to school or into other group situations. The individual comes in for a nurse-only visit for a rapid strep test and culture. If the strep test were negative, the family practice coder would assign 99211. But if the culture indicates strep, it is likely the physician would see the patient. The physician most likely would take an appropriate medical history related to strep, conduct a review of symptoms (ROS), including fevers or skin rashes, and perform an appropriate ears, nose and throat (ENT) exam. For these services, E/M code 99213 would be assigned and 99211 would not be billed.

Incident to Guidelines Apply to Nurse Visits

Nurses who bill 99211 must follow the incident to guidelines set forth by the patients insurance carrier. Medicare specifies that practices billing incident to must meet carrier requirements, which state that the physician must be on-site at the time of treatment, the physician must have originally seen the patient for the first visit to the office or clinic, and the physician must see the practices established patients for any new medical problems.

When billing 99211, the nurse should document the date of the visit, a brief description of the reason for the visit and the services provided, says Mulholland. The name of the supervising physician also needs to be identified in the notes. Something like, April 5, patient came in for blood pressure check to ensure hes doing okay on his new pain medication. Performed review of systems; no adverse effects found. Dr. Jones on-site. That way, if an auditor ever came in, they would know that the physician was available to the nurse. In the absence of the declaration about the doctor being on-site, the physicians signature and date (and comments, as appropriate), also could justify the physicians supervision of the service.

Mulholland adds that the guidelines for billing 99211 also apply to the services of physicians assistants (PAs) and nurse practitioners when their services are billed incident to the doctors services. But PAs and nurse practitioners also have their own billing numbers, and when they bill using their own billing numbers, they use the same guidelines as a physician. In any case, the services an RN (registered nurse), PA or nurse practitioner provides will depend on his or her scope of practice and will vary on a state-to-state basis. So check with your local provider to be certain of its requirements.