Check These Four Documentation Rules for Reporting 99211

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Check These Four Documentation Rules for Reporting 99211

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CPT code 99211

Your nurses are vital to your office’s operations, and the income they generate is vital as well. But if you don’t ensure that they document their visits properly, you could be throwing thousands of dollars out the window. That’s because payers and government auditors are reviewing documentation for nurse-visit CPT code 99211, and if they find improprieties, you could not only lose money, but you could also face legal issues.

Consider the following tips to ensure you’re documenting your services accurately before you report CPT code 99211:

1. Go Beyond Vitals

Some practices assume that if they record a patient’s vitals (blood pressure, temperature, weight, etc.), they can report 99211, no matter what else they document, but this is inaccurate. Without proof of medical necessity, the visit won’t be payable. Therefore, recording the patient’s vitals can be a great start, but there’s much more to it than that.

2. Include Proof of Evaluation, Management

As an evaluation and management (E/M) service, your documentation must demonstrate that a clinically necessary, clinically relevant exchange of information between the provider and the patient took place. In this case, the nurse is the provider, so you should document what the nurse did and why.

For instance, clinical documentation for a wound dressing would include a description of the wound, a description of how it was dressed, what supplies were used, whether it was well healed, where on the body it was, whether any infection counseling took place, what subjects were discussed, and any other relevant issues.

3. Demonstrate Medical Necessity

Like all other services you bill to insurers, the nurse’s service must be medically necessary, or your payer won’t reimburse you for it. Even if you have pages and pages of documentation, you’ll collect nothing from the insurer if you don’t include medical necessity somewhere in there.

For example, suppose a patient sees the nurse for a blood pressure check. In many cases, patients can get blood pressure checked at home, at a drug store, and even at a local fire station. So to demonstrate that they came to your practice for this and saw a nurse would require you to document why. For instance, “Patient presented for a blood pressure check today at the request of Dr. Jones because she had been having side effects from the Vyvanse dosage change that occurred on Oct. 15, 2022. Today’s blood pressure was 122/79, which falls within normal limits, so the patient was advised to continue monitoring at home and to call us if her BP rises or falls outside of the normal range. She will follow up with Dr. Jones in two weeks.”

Remember that the nurse isn’t diagnosing the patient—they are only continuing the plan that the provider established. But your documentation should still include the reason necessitating the visit. For instance, “I saw the patient today to perform wound care following Dr. Smith’s Oct. 23 diagnosis of a pressure ulcer. The wound appeared to be healing well and after I replaced the bandage. I advised the patient that she should continue Dr. Smith’s advice to change the dressing at home every other day.”

4. Show That Incident To Requirements Were Met

You must demonstrate that you’ve met the requirements for billing CPT code 99211 as an incident to service. You’ll be able to show that the nurse was an employee of the practice by sharing HR records if required to prove that, and you will also need to be able to prove that the physician was in the clinic and immediately available if needed. You can do this by showing your appointment book or other proof that the doctor was there.

You’ll also need to be able to demonstrate that the physician or a nonphysician provider set up the original plan of care, which you can typically find elsewhere in the patient’s record. This is an essential element when reporting incident to, because you’re basically asking the insurer to accept the fact that your nurse was simply following the provider’s plan of care.

Although it isn’t required under the incident to guidelines to have this information in the documentation, it can be helpful somewhere in the nurse’s note on the date of service to document:

  • Whose plan of care the nurse was following
  • Which provider was in the office that day and was immediately available providing supervision
  • A signature from the supervising provider (required by some insurers but not all)

By ensuring that anyone looking at your documentation will be able to see medical necessity, the reason for the visit, proof of what was done, and the fact that you met the incident to guidelines, you can rest easier in your nurse-visit documentation.

Want to get paid for more of the services your mid-level providers provide? Sign up for the online training, CPT Code 99211: Get $23 Per Patient on Nonphysician Work. During this 60-minute training event, Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, will show you precisely how to accurately use CPT code 99211 and help you get paid more per visit.


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