Pulmonology Coding Alert

Question: A patient presented to our office for a chest x-ray, but before the doctor interpreted it and gave her the results, the patient got an urgent phone call and had to leave. Should we report 99211 for the visit?

Codify Subscriber

Answer: No, you cannot 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 or other qualified health care professional…) for this visit because it doesn’t sound like anyone performed an actual E/M service in this situation.

You can report the chest x-ray (for instance, 71010, Radiologic examination, chest; single view, frontal), once the physician interprets the result. Diagnostic testing does not require that the interpreting physician have a face-to-face encounter with the patient. It requires that the technical portion is performed (i.e., the images are taken), and the professional component is provided (i.e., the images are interpreted with a formal report of the findings). The patient is not required to stay until the physician interprets the results. If the patient leaves, you are still obligated to notify them of the results.