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Pulmonology Coding Alert

A Quick Check of 99211 Requirements Will Guarantee Payment

Published on Sat Sep 17, 2005

Follow these 7 guidelines to determine whether 99211 is appropriate

If you're not sure whether you should bill 99211 in addition to other codes, these expert tips will help ensure that you get the most out of 99211:

Do:
 
  • Make sure there is a separate E/M service. Check for documented evaluation, along with management of the patient's care. For example, if the nurse only refills the patient's medications and no other E/M service takes place, you should not 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).
     
  • Ensure the patient is an established patient. Based on the CPT code description, you report 99211 for a patient who has been seen by the pulmonologist or another physician in the practice within the past three years, in any setting. Therefore, you cannot report 99211 for a new patient.
     
  • Be certain that the physician is in the office. Reporting 99211 to certain payers, such as Medicare, requires that the pulmonologist be in the office suite at the time of the appointment. The doctor is not, however, required to be in the room or to come face-to-face with the patient.
     
  • Prove that the nurse visit is medically necessary. Look for a documented clinical reason that supports the nurse visit and proves it was above the scope of the other services provided that day. "If reporting the code with a procedure, make sure the documentation is separate and identifiable," says Michele Wendling, billing manager with Midwest Medical Services in Troy, Ohio.

    Don't:
     
  • Bill for a nurse visit for services that are part of another E/M service performed on the same day. For example, if your nurse measures the patient's blood pressure and weight prior to her visit with the pulmonologist or provides counseling after the physician has seen the patient, you should not use 99211, as those tasks are considered part of the physician's office visit.
     
  • Report 99211 for telephone calls. There must be face-to-face contact in order to report 99211. For example, if a nurse returns a patient's call and gives instructions over the phone, you can't submit 99211 for reimbursement.
     
  • Underestimate the importance of documentation. Documentation is essential when requesting reimbursement for nurse visits. "Make sure that you meet the documentation requirements, which are very basic," Wendling says. The reason for and details of the encounter, which may include educational services as well as evaluation of the patient's condition with management directed by the physician, must be documented.

    For example, you must have documentation to show that the supervising physician was in the office at the time of the visit. In this instance, your documentation might be a statement indicating that the nurse was working under a physician in the office or a copy of the physician's schedule, which shows she was in the office at the time of the nurse visit. The physician may alternatively decide to include a comment with his signature and the date.

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