JoAnne: Q: [99211 CPT Code] Can someone please discuss the 99211 CPT Code?
A: 99211 is defined as an office or outpatient visit for the evaluation and management of
an established patient that may not require the
presence of a physician.
Presenting problems are minimal, five minutes is typically the time spent performing or
supervising the service.
Physicians don’t typically use the 99211, it really was intended more for a nurse or
a medical assistant.
Unlike other office visits, the 99211 does not have any specific key component documentation
requirements.
The patient has to be established.
There’s some degree of medical decision making that takes place.
But if a clinical need is not substantiated, you cannot bill it.
The big difference here between Medicare and other insurances or CPT, is that in CPT, the
presence of a physician is not required.
A lot of insurance companies follow that guideline.
Medicare says a physician must be in the office suite, which means it’s like billing incident-to,
they have to be within shouting distance, not across the path of the hospital and not
by cell phone, they have to be in the office.
When to Not Use 99211; Examples – The patient comes in once a month for B-12 injection and
the doctor just gave a shot and that’s it; then, you’re billing a 96372 with a HCPCS
J3420 for the B-12, and that’s it!
If a patient walks in with a little bottle of allergy serum and the nurse gives her a
shot, there’s no 99211.
If you’re picking up a script, dropping off urinalysis, even if it is face-to-face,
it’s not 99211.
When to bill 99211 – If a patient is seen by a nurse because of urinary burning and
frequency, the nurse takes a quick look, focused history, reviews the medical record, and orders
a urinalysis.
He has an infection, shows to the doctor, the doctor writes a script.
But it’s really a very quick visit.
If the physician requests the patient to go into the office for a blood pressure check
because he has problems with hypertension, that qualifies for 99211.
If the patient calls for a visit because he has clinical indications that his blood pressure
is off the map, that is a clinical indication you can bill.
But I know for a fact that small, little country doctors and on in the islands, everyone knows
everybody, a patient just walks in and say, “Hey, doc, can you check my blood pressure?”
That doesn’t cut it; so you can’t bill 99211 for that.
That’s very important.
What I do want to stress though is that there are some doctors that think they can get away
with this, they’ll tell the nurse, do the vitals, bill a 99211 with the B-12 shot.
But when the insurance pays, write off the copayment, you cannot do that, it is totally
illegal.
The physician has a contract with the insurance company and he’s breaking his contract,
and if the patient doesn’t pay, they are breaking their contract.
I haven’t seen one doctor in my lifetime go to court because they didn’t collect
copayments for their patients.
So, don’t play that game, it’s not worth taking that risk.
That’s basically it for 99211.
Alicia: I’ve seen that happen too, it was really difficult to try to explain why that…
JoAnne: They get angry because they’ll say, “I was just in there for a shot, why do
I have to pay $25 copay?”
They don’t like it.
Alicia:And the office staff or the physician thinks they’re giving
you a discount by making you do that.