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1 Myth and 3 Truths About When to Use CPT Code 99211

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1 Myth and 3 Truths About When to Use CPT Code 99211

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You may think you know everything possible about CPT code 99211—or maybe you’re one of the people who thinks there isn’t much to know about this code. After all, some practices simply assign it to every service the nurse provides and move on. This strategy can backfire as audits of 99211 ramp up and payers grow increasingly less eager to pay even lower-reimbursing claims without a fight.

That’s why it’s essential to understand some of the most common myths and truths about 99211.

Myth: Physicians Are Barred From Billing 99211

Some practices follow the common belief that physicians are prohibited from reporting 99211, but this is actually a myth. In reality, your physicians can report 99211 if their documentation justifies this code.

Will their documentation justify it? Probably not, most coding experts say.

Here’s why: If the physician documents even the lowest-level E/M service with straightforward medical decision-making (MDM), then they’ve met the requirements for instead reporting 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter), which is a higher paying code.

The bottom line is that although physicians are not barred from reporting 99211, they will do so infrequently, if at all.

Truth 1: You Shouldn’t Report 99211 When Another Code Describes the Service

Although 99211 is typically described as “the nurse’s code,” it’s not designed to serve as a catch-all for everything your nurse does. If another code more appropriately describes the service that your nurse provided, then you should report the code describing that instead.

For instance, suppose a patient arrives at your office for a scheduled allergy injection, along with no other services. The nurse administers the injection and the patient checks out. In this case, you’ll report the most appropriate injection code instead of 99211.

Truth 2: You Must Meet Incident To Rules

When reporting 99211, you’ll bill it as an incident to service, so you must meet the incident to requirements:

  • The patient must be established
  • The physician or nonphysician provider must have created the plan of care
  • The service must be performed in the physician office (place of service 11)
  • The service must occur under direct supervision, meaning the doctor is immediately available
  • The nurse must be an employee of the practice

If these criteria aren’t met, you can’t report 99211. For instance, suppose the patient presents for a blood pressure check and says “Oh, by the way, I also have new back pain that started this morning. What can I do?” In this case, the nurse won’t be able to address the back pain in the 99211 visit for that day, because it’s a new problem, and therefore the physician hasn’t yet created a plan of care for it. The nurse must instead ask the patient to see one of the clinicians to evaluate that new problem.

Truth 3: Documentation Must Be Pristine

You can never skimp on 99211 documentation under the guise that anything will justify such a low-level visit. You must document the fact that an evaluation and management service was performed, that it was medically necessary, and that the incident to guidelines were met.

The documentation must include more than just vitals. It should also say what service the nurse performed. For instance, did you dress a wound, remove sutures, counsel the patient, or give an injection? If so, document that in the notes.

Seeking more tips about how to report your mid-level providers’ services? 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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