Bringing additional revenue into your practice can be challenging. RT Welter’s 99211 factsheet was created to assist you in reporting 99211 so that you can ensure you don’t miss out on the revenue you deserve. Continue reading below for more information.
Ginger Avery, CPC, CPMA, CRC
Coding & Compliance Manager
With a current reimbursement rate of $23.73, it is evident that reporting 99211 can bring additional revenue into your practice. Reporting just five 99211 encounters per week could result in over $5,600 per year. The following guidelines can help assure you maintain compliance and receive the revenue that you deserve for the services you may already be providing.
CPT defines code 99211 as an “office or other outpatient visit for the evaluation and management (E/M) of an established patient, which may not require the presence of a physician.” It also specifies that the presenting problems are usually minimal.
- The provider-patient encounter must take place face to face. You may not bill code 99211 for calling the patient, writing a prescription, “calling in” a prescription to the pharmacy, or e-mailing a patient.
- The patient must be an established patient who has been seen initially by the physician so that the services of the staff person are incident to the treatment plan established for that patient by the physician and all other requirements pertaining to incident to policy are met.
- The E/M service provided must be medically necessary and separate from other services rendered.
- You can bill only one E/M code per day, per practice.
- If the patient is not seen by the physician, bill visits under the incident-to Medicare guidelines.
- The incident-to Medicare guidelines include having a physician present within the office suite.
- Services must be billed under the physician who is present within the suite.
- Some private policies require that if you bill a 99211, the doctor has to see the patient every 3rd visit. Be sure to check with top payers for recent updates.
Examples of services that may be billed using 99211, assuming they are documented well and medically necessary:
- A blood pressure evaluation at the request of a clinician (follow up BP check ordered) ∙ Suture removals outside of global services (original procedure performed elsewhere) ∙ Dressing Changes
- Refilling medication may be billed if the patient is receiving ongoing management by the physician and the prescription is part of the treatment. If a patient came in and needed some counseling about a new regimen of medications.
- Nurse sees patient for urinary burning, nurse discusses with clinician, labs ordered/reviewed & Rx ordered.
- Discussion with patient following laboratory tests that indicate the need to adjust medications or repeat order of tests
- Protime code 85610 includes evaluation. When patients on anticoagulants come in for routine prothrombin tests, 99211 is a billable service, but only when the dosage or some other aspect of the regimen is being adjusted. When no change is made, 99211 is not billable.
Examples of services that may not be billed using 99211, even if they are medically necessary:
- Phone Calls
- Prescriptions Refills
- Drop-in Blood Pressure checks without clinical indicators
- Blood draw – should be billed using 36415, 36416, or G0001.
- Laboratory tests – The lab performing the test should bill Medicare using the appropriate CPT code.
- Chemotherapy injections – Bill using the appropriate chemotherapy injection code (96400 or 96408).
- Assessment of a patient or flushing of a vascular access port prior to administration of chemotherapy.
- Monitoring of cardiology tests, such as thallium stress tests, where such monitoring is inherent in the performance of the test.
Documentation Tips: When documenting a 99211 more is better. Staff should have a solid understanding of the incident-to, supervision and regional or state scope of practice rules, and local medical review policies for these services. Although code 99211 doesn’t require the key components of the E/M codes, documentation should include some degree of the patient’s history, a limited exam, and/or medical decision-making to show medical necessity of the visit.
Staff members who are cognizant of billing and coding guidelines tend to pay increased attention to the quality of documentation, which, can result in a more useful medical record for all providers involved in the care of the patient.
Use good judgment when reporting 99211, not every encounter has clinical indicators that support medical necessity. Be cautious of establishing blanket policy practices for “nurse visits”, ethical standards still apply.
COVID Waiver Information*: For the duration of the PHE, Physicians and NPPs may use CPT code 99211 to bill for services furnished incident to their professional services, for both new and established patients, CMS-5531-IFC 192 when clinical staff assess symptoms and collect specimens for purposes of COVID-19 testing.
This waiver permits the direct supervision requirement to be met through virtual presence of the supervising physician or practitioner using interactive audio and video technology for the duration of the PHE (85 FR 19245).
*Waivers currently are ending through individual payers on a daily basis. Check with your payers for the most recent updates.