Wiki Medication count

[oskolkoff]

Can 99211 be billed along with the Urine Drug Screen test when the patient sees the nurse and a suboxione count is done? No vitals are preformed. The Dr will review the note later and prescribe refills. There is no documentation from the Dr on this encounter. Our office is evenly split between yes and no.

Thanks for the help with this sticky problem,
Jennifer

 

[Chelle-Lynn]

CMS carrier Noridian states that if the sole purpose of a visit to a physicians office is to perform a lab procedure of receive an injection then 99211 should not be billed. Instead you would bill the appropriate injection or blood draw code.

As always any E&M including 99211 still requires medical necessity and appropriate documentation. The medical records would need to show that on the date of service the patient met 2 or the 3 requirements for an E&M level. See the following example:

Noridian gives the following example of a payable 99211 visit: “Office visit for an established patient with a concerning bruise, which is checked by the nurse and patient is advised on how to care for the bruise and what to be concerned about. History, exam, and MDM are recorded by the nurse and reviewed by the physician.”

So in your case...the lab is being performed to determine if the a script is needed. This is not enough to level the claim to a 99211 as 2 of the 3 are not met. Only MDM by the physician.