It’s about time for this nonphysician provider E/M code change.
How do you feel you are handling the new American Medical Association (AMA) evaluation and management (E/M) guidelines? I know I’ve had to stop many times while auditing and make sure I was using the new criteria for office visits. I’ve even tried to use the new guidelines on hospital visits accidentally. I bet I’m not alone! A quick review of how to report CPT® code 99211 is a good idea for us all.
Proper Use of 99211
CPT® code 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 confused many of us even before the new 2021 guidelines. Providers were trying to use it for quick visits with patients, which isn’t necessarily wrong … it was just potentially shortchanging them since 99212 is for straightforward medical decision making and should be the lowest level used by a provider in the office. Even with the new guidelines, that has not changed.
Physicians can report 99211, but it is intended to report services rendered by other individuals in the practice, such as nursing staff, medical assistants, or technicians, who must document the visit just as a provider would. Common examples include hypertension or wound checks by a nurse or medical assistant. The new AMA definition of a “minimal” problem is a problem that may not require the presence of the provider, but the service is provided under their supervision.
One change to 99211 in 2021 has to do with time. Previously, the code descriptor stated, “Typically, 5 minutes are spent performing or supervising these services.” For dates of service on or after Jan. 1, 2021, you cannot bill 99211 based on time alone, as you can for the rest of the office visit codes. A nurse can document the amount of time spent in the medical record, but you cannot use that time for code level selection.
99211 Must Meet Incident-to Requirements
If that last bit sounds familiar to you, it’s because of the incident-to rules. All 99211 services must meet these three requirements of incident-to:
- The services are rendered under the direct supervision of the physician or nonphysician practitioner (NPP) (i.e., nurse practitioner (NP), certified nurse-midwife (CNM), clinical nurse specialist (CNS), or in the case of a physician-directed clinic, the physician assistant (PA)).
- The services are furnished as an integral, although incidental, part of the physician’s or NPP’s professional services in the course of the diagnosis or treatment of an injury or illness.
- When billing incident to the physician, the physician must initiate treatment and see the patient at a frequency that reflects their active involvement in the patient’s case. This includes both new patients and established patients being seen for new problems. The claims are then billed under the physician’s National Provider Identifier (NPI).
If the patient sees a nurse for a dressing change as per the physician’s orders and the patient brings up another condition, the service no longer qualifies as incident to, and you cannot bill 99211. The physician will need to see the patient and bill the appropriate level of E/M.
Understand Scope of Practice and Other Specifics
The term “scope of practice” refers to the regulations, which vary by state, specifying which services each staff can perform. Be aware of your state’s definition of scope of practice for each credentialed NPP to be sure they are qualified to perform the services described by 99211.
Is it appropriate to bill 99211 when a patient presents for an injection?
No. When a patient presents for an injection, code for the injection administration (i.e., 90471, 90473, 96375). Do not bill 99211 unless the patient is also seen for a different reason that qualifies for modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.
When reporting 99211, make sure the documentation includes anything the NPP did such as vitals, discussing current medications, or answering patient questions. Documentation should also include the reason for the visit and the diagnosis, along with any applicable orders or discussions the NPP had with the physician about the patient.
Perform a few 99211 audits and make sure to update any templates being used to ensure compliance with the new 2021 guidelines. Educate both clinical and billing staff on proper documentation and follow AAPC Services Group for more updates.