Urology Coding Alert

Tip: Always know who provided the service.

Of all the outpatient evaluation and management (E/M) codes, none is more misunderstood than 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).

So says Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America. The problem is that “the description says, ‘may not require the presence of a physician,’ so it usually winds up being used when the physician is not immediately available,” Hauptman cautions.

That’s why coders always have so many questions about how to use 99211. Here are three of the most frequently asked questions, along with some expert answers to help you sort fact from fiction.

Question 1: Can I report 99211 when a physician or non-physician practitioner (NPP) provides the service?

Answer 1: “Code 99211 is used when nurses see patients for discussions or quick follow-ups at the request of the physician. Whoever administers the service does such things as take vitals and blood pressure with the right diagnosis,” Hauptman reminds coders.

So, while physicians and NPPs can technically perform 99211 services, it’s not a good idea for them to do so.

“If it is necessary for a patient to see a physician or NPP, you should at least document a 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) or a procedure code for the medical necessity of the visit,” says Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB,  owner/consultant of Professional Coding Solutions in Holcombe, Wisconsin.

Question 2: Who is responsible for documenting 99211 if it is supervised?

Answer 2: “One of the most common mistakes I find with 99211, especially for Medicare patients, is that there must be a physician-documented request that the patient be seen for some kind of follow-up with staff personnel,” says Rasmussen. “The request could be in the form of a statement in a patient encounter such as ‘follow up with x in one week for a blood pressure check,’ or it could be in the form of a formal order, but it must be somewhere.”

More, “the service documented must be medically necessary. I like to see the nurse/personnel seeing the patient for a 99211 document the request and by whom, the medical necessity of the service, and what occurred during the service,” Rasmussen adds. There may be recorded a brief history, physical examination, and medical decision making.

Question 3: Can I use 99211 when patients drop off specimen samples or paperwork, or pick up a prescription?

Answer 3: If the patient is just dropping things off to, or picking things up from, your front desk, the answer is “no.” However, if the patient has a face-to-face meeting with your urologist, a qualified healthcare provider (QHP) such as a physician assistant (PA), a nurse practitioner (NP), or a member of your clinical staff in order to review side effects of a prescribed medication or how it should be taken, that would justify documenting 99211. Simply put, the encounter should be face-to-face, and it should be for the “evaluation and management” of the patient as the code descriptor says.