Pulmonology Coding Alert

No face-to-face time with nurse or physician? Find out if this qualifies.

Is your pulmonologist practice seeing established patients for a quick visit to assess the patient’s breathing status after initiation of a new medication, for example? Then you should most likely be turning to 99211. This code allows certain qualified professional staff to attend to low-level E/Ms, which lets physicians focus on patients that require more attention.

Overlooking these visits, however, can be a mistake, because 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) could be a big contributor to your practice’s bottom line.

As with every code, there are rules to be followed on 99211 reporting. Use this list of tips to streamline and maximize your 99211 reporting.

Tip 1: Prove Entire E/M Visit Via Documentation

To report 99211, a practitioner must perform an E/M service. In other words, it isn’t a catch-all code that you can report every time a patient passes through your practice.

Example: A nurse speaks to a patient on the phone and agrees to obtain a prescription refill for her. The patient comes to the practice an hour later, and the nurse hands her the prescription through the reception window.

Solution: Because the nurse did not evaluate the patient, and no medical necessity required that she meet with her, you should not report an office visit. If the physician wanted the nurse to assess the patient for adequacy of medication therapy prior to renewing the patient’s prescription, however, the nurse would have to document the evaluation and management to support the medical necessity for billing 99211.

Whenever you report 99211, the provider should document the reason for the visit, a brief (interim) history of the patient’s illness, any pertinent physical exam (vital signs are commonly expected by contractors in note audits of 99211) and the management provided through the physician’s direction. A brief evaluative statement is good practice.

Also, make sure you have the date of service, the reason for the visit, proof that the nurse performed the service per the physician’s order, and the nurse’s legible signature. For example, “Pt comes in for re-eval of lungs after 4 weeks on new medication. No further respiratory symptoms since staring Singulair; rescue inhaler not used in 3 weeks. I reported pt progress to Dr Jones who advises pt to continue Singulair. Refill provided. Follow-up with Dr Jones in 3 months; call if symptoms worsen.”

Tip 2: Be Familiar With 99211 Components

The description for 99211 states, “for the evaluation and management of an established patient.” When patients come in and weigh themselves, or simply hand you a form for the doctor to complete and don’t require any face-to-face time with a physician or nurse, that doesn’t meet the code’s requirements.

In some cases, a prescription pickup or form completion could require an assessment visit to take place, and in those cases, 99211 is appropriate if the documentation supports that patient management occurred.

For instance, a patient presents to pick up a prescription and the patient requests to speak with the provider about medication use. The nurse meets with the patient to review the prescription to make sure the patient is properly educated on how to take the medication, review side effects, etc., then it could qualify. The code states, “typically, five minutes are spent performing or supervising these services,” so it’s OK if the visit or face-to-face time isn’t long. But enough has to happen that the nurse can write a progress note, and that some brief physician’s time to supervise the service is warranted. Remember, that you should not charge for a visit if the visit was not prompted at the request of the physician or at the request of the patient for a specific patient need.

Tip 3: Remember ‘Established Patient Rule’

You shouldn’t forget the fact that 99211 only applies to established patients, not new ones. If a nurse practitioner saw a new patient for a low-level visit, you’d instead report 99202 (Office or other outpatient visit for the evaluation and management of a new patient ...) — but medical assistants or registered nurses cannot use a code other than 99211.

Code 99211 is only for established patients because it is technically performed incident-to a physician. To meet the guidelines associated with incident-to, the patient must have a plan of care that has already been created by a supervising provider. The nurse would be providing services directly indicated and/or appropriate to the established plan of care. The supervising provider (a physician or NPP) submits the bill.

Tip 4: Physicians Can Report 99211

When necessary, a physician or other qualified nonphysician practitioner (NPP) can use 99211, despite the fact that many practices refer to it as a “nurse’s code.” Any qualified personnel can report 99211, including physicians, medical assistants, licensed practical nurses, technicians, and other aides working under the physician’s direct supervision, depending on state law. Most typically, a physician or NPP providing a brief service would utilize 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.) to reflect very limited history and/ or physical exam and straightforward medical decision making, such as renewing a low-risk medication.

Tip 5: Look Out for Bundles

Although 99211 is often the best choice when a clinician performs a quick, medically necessary visit, payers won’t always reimburse it. The Correct Coding Initiative (CCI) bundles 99211 into several other codes, and some payers maintain their own edits for it.

For instance, CGS Medicare says on its website, “Code 99211 is always bundled with injection administration procedures. CMS guidelines specify that the administration of injections is only paid separately when there is no other physician fee schedule service paid on that date of service for that provider.”

Remember: If a patient is coming in for a specific procedure (eg, allergy injection or PFTs) without further evaluation and separate medical management, you would not report 99211 (or any other E/M code) in addition to the procedure.