You must have scheduled evaluation and management (E/M) visits for new and established patients frequently in your career. For that, your go-to CPT code ranges must have been 99202-99205 and 99212-99215. But what about CPT code 99211, which sits right at the top of the established patient CPT code range?
If you are as intrigued as us about the use of code 99211, then read this guide till the end. We will cover the description, application, differences, and billing best practices for the 99211 CPT code.
CPT Code 99211 – Description
The Current Procedural Terminology (CPT) code 99211 is an evaluation and management (E/M) visit code for established or returning patients. The provider or the billing team uses this code to inform the insurance payer that an established patient was rendered E/M services in an outpatient or office setting without the physician being present.
This is why sometimes it is called “the nurse’s code”. The nurse or another qualified healthcare professional evaluates the patient’s condition and creates a plan of care for appropriate management of the disease or disorder. You must also note that this E/M visit typically lasts 5 minutes or less.
A few conditions must be met to report the CPT code 99211, as listed below:
- The patient must be established (the provider has met and treated the patient before).
- The service is rendered in the provider’s office – Place of service code 11 (POS 11).
- The patient is served under the physician’s direct supervision (the physician oversees care virtually or immediately takes over from the nurse upon reaching the office).
- The service is provided by a licensed nurse or another qualified physician staff who is an employee of the same practice.
- A care plan is created and delivered to the patient during the E/M visit.
The current Medicare reimbursement rate for CPT code 99211 is around $24 per claim.
Scenarios Where CPT Code 99211 is Applicable
Before we discuss the scenarios for which the 99211 CPT code can be appropriately used, let’s first understand when and why payers advise against code 99211. This CPT code should not be used when an E/M visit involving a higher degree of medical complexity takes place on the same day at the same place.
So, for example, the physician reaches his office late, but his nurse is available and renders the medically necessary services in that situation. If the patient stays long enough to meet the physician and the physician performs a thorough evaluation that includes a higher level of medical decision-making, only the physician’s services will be billed. This is because another established patient E/M visit code between 99212 and 99215 will invalidate CPT code 99211.
However, code 99211 becomes applicable in the following circumstances.
Billing Nurse Visits
It is appropriate to use CPT code 99211 when a nurse meets an established patient in the physician’s office in his absence to provide medically necessary E/M services like a clinical examination, taking down the patient’s medical history, or making revisions to the treatment plan after being guided by the physician. Therefore, the nurse can use code 99211 to bill her services under the incident-to-rule.
Billing Physician-Approved Care Plan
A physician is out of the office for personal reasons, and during this time, an established patient visits the clinic complaining of pain and discomfort in the urinary tract. The nurse or physician’s assistant (PA) takes clinical notes of the patient’s symptoms and communicates this to the physician. The physician evaluates the symptoms and prescribes antibiotics for the urinary tract infection. The nurse or PA hands over this prescription to the patient with instructions and records the encounter in the EMR system.
So, in this case, the nurse or PA can bill the encounter with CPT code 99211 to denote that a physician-approved care plan was offered to the patient.
Billing Simple Wound Dressing
The 99211 CPT code can also be used when an established patient visits the doctor’s office for simple wound care or dressing change. The service may be a part of ongoing care or treatment for a new injury. The physician instructs the nurse or his qualified staff member to assess the open wound and dress it with the appropriate topicals and bandaids. However, this code cannot be used for burn treatments or post-surgery care.
Billing Suture Removals
If the patient’s wounds or incisions were stitched at another healthcare practice but he wishes to have them removed from a known medical facility, CPT code 99211 can be used to report these suture removals. The physician may or may not be present during the procedure. However, clear instructions are given to the nurse, PA, or any other qualified practitioner on what must be done. Since a specific CPT code for suture removal is unavailable, 99211 would suffice.
Billing COVID-19 Specimen Collection
99211 CPT code can also be reported for COVID-19 testing. For example, code 99211 is used when the lab technician, PA, or nurse collects specimens for COVID-19 tests from an established patient at a physician’s office. However, the provider must initiate the test as a result of acknowledging the patient’s symptoms (to prove the medical necessity of code 99211) and not because the patient wishes to get tested for COVID-19. The primary physician may or may not be present during this testing.
CPT Code 99211 vs. 99212 – Key Differences
CPT codes 99211 and 99212 both denote E/M services for established patients. However, some key differences make the two codes distinct. Refer to the table below to understand the differences between CPT codes 99211 and 99212 and avoid coding confusion.
| Comparison | CPT Code 99211 | CPT Code 99212 |
|---|---|---|
| Visit Duration | 5 minutes | 10+ minutes |
| Service Provider | Nurse, physician assistant, or technician | Physician |
| Physician’s Presence | Not required | Required |
| Patient’s Condition | Minimally complex | Slightly more complex |
| Level of Medical Decision-Making | Basic | Straightforward to moderate |
| Documentation Requirements | Does not include specific key components, e.g., the patient’s detailed history or examination | Includes specific key components, e.g., the patient’s detailed history or examinations |
Best Practices for Billing CPT Code 99211
CPT code 99211 is a unique ‘established patient’ E/M visit code that can become invalid and non-payable if best practices for billing are not followed. To avoid payment delays and denials, ensure that you follow these guidelines when billing physician-supervised E/M services against code 99211.
Ensure that the Patient is an Established One
Your first consideration when billing CPT code 99211 should be to verify whether that patient was new or established. You can refer to the clinical logs and patient records to confirm that the patient has received services from the same physician in the past.
Double-check the Status and Designation of the Provider
Next, you must confirm who delivered the E/M services and what the mode of delivery was. For example, if a physician rendered the services personally, CPT code 99211 will not be applicable.
However, if a physician guided his staff, in-person or virtually, during the visit, CPT code 99211 can be reported. The best use case for code 99211, however, would be when services are rendered by clinical staff (nurse, PA, or technician) in the absence of the physician but within his knowledge.
Confirm the Medical Complexity Level
You must refer to the clinical notes and any other documentation that the clinical staff maintained during the visit to gauge the medical complexity level of the encounter. For example, if the patient visited the physician’s office as per a scheduled appointment or because of minor discomfort, CPT code 99211 would be applicable.
However, if the patient exhibited acute symptoms and required a high degree of medical decision-making for its management, then code 99211 would become invalid. In this case, you would have to report one of these four codes – 99212, 99213, 99214, or 99215.
Verify the Duration of E/M Service or Visit
Before reporting CPT code 99211, you must speak to the clinical staff who performed the E/M service and inquire about its duration. If the service lasted longer than 5 minutes, code 99211 would no longer be relevant. However, if the clinical staff spent 5 minutes or less with the patient, then 99211 would be usable.
Comply with Medicare Requirements for Medicare-Insured Patients
You must ensure the visit was physician-initiated to bill the 99211 CPT code to Medicare. Medicare does not mandate direct contact between the physician and the patient for billing code 99211, but it does want the physician to be in the same office when the service is provided. Hence, it is recommended that the physician see the established patient at least once in every third visit to ensure the continuity of quality patient care.
Document the Medical Necessity of the Service
You will have to prove the medical necessity of physician-supervised E/M service to collect reimbursement against code 99211. For example, you cannot bill CPT code 99211 if the patient walks into the office to collect a prescription he forgot to retrieve earlier. E/M services, like specimen collection, wound dressing, blood pressure checks, and adjustment of dosages, must only be delivered if the patient’s condition necessitates them. Moreover, the clinical staff should record the patient’s condition before and after the service to prove its medical necessity during claim submission.
Bill it When No Other Appropriate E/M CPT Code is Available
You can only use the 99211 CPT code for E/M services rendered to established patients when no other code from the 99212-99215 range fits the description. For example, you should only claim code 99212 if 99211 and 99212 were performed on the same day for the same patient to get a better reimbursement rate for a more complex service. However, if only 99211 was performed, bill it using the appropriate CPT code.
Conclusion
CPT code 99211 can be applied in numerous situations where a physician’s direct presence is not required to deliver E/M services to an established patient. Any member of the clinical staff, preferably a nurse, can render medically necessary and physician-initiated care services to assess and manage the patient’s condition. However, the code must not be confused with other established patient E/M service codes and reported only when all its conditions are met.
If you are still unclear about the appropriate usage of code 99211, don’t worry. At MediBill MD, we offer professional medical coding services to ease your CPT coding aches. Our AAPC-certified professional coders know the precise moment to bill the 99211 CPT code and capture maximum reimbursements.
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