630 South Church Street, Suite 300 Murfreesboro, TN Understanding When to (or not to..) Use Many physicians and coders still struggle with when - or why - to report the code

99211 Defined Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing these services.

Benefits of using the Code  Additional revenue into your practice – although specific payment amounts will vary by payer, the average unadjusted 2004 payment from Medicare for a service was $21.  Just five encounters with Medicare patients per week = $5,000 per year This may not sound like a get rich idea, but it’s easy revenue.

 Most practices already provide a number of services but fail to capture those charges  If you are accurately reporting services you will also improve documentation in your practice. Staff members who are cognizant of billing guidelines tend to pay increased attention to documentation, which, in turn, will result in a more useful medical record for all providers involved in the care of the patients. Benefits of using the Code

When to Use the Code  The patient must be established  The provider-patient encounter must be face- to-face  An E/M service must be provided  The service must be separate from other services performed on the same day  The presence of a physician is not always required  No key components are required

When to Use the Code The patient must be established. According to CPT, an established patient is one who has received professional services from the physician or another physician of the same specialty in the same group practice within the past three years. Code cannot be reported for services provided to patients who are new to the physician.

When to Use the Code The provider-patient encounter must be face-to-face. For this reason, telephone calls with patients do not meet the requirements for reporting (* but there IS a set of telephone consult codes)

When to Use the Code An E/M service must be provided. Generally, this means that the patient's history is reviewed, a limited physical assessment is performed or some degree of decision making occurs. If a clinical need cannot be substantiated, should not be reported. For example, would not be appropriate when a patient comes into the office just to pick up a routine prescription. Keep in mind that if another CPT code more accurately describes the service being provided, that code should be reported instead of For example, if a physician instructs a patient to come to the office to have blood drawn for routine labs, the nurse or lab technician should report CPT code (routine venipuncture) instead of since an E/M service was not required.

When to Use the Code The service must be separate from other services performed on the same day. Services that are considered part of another E/M service provided on the same day should not be reported with code For example, if a nurse provides instructions following a physician's minor procedure or takes a patient's vital signs prior to an encounter with the physician, should not be reported for these activities because they are considered part of the E/M service already being provided by the physician.

When to Use the Code The presence of a physician is not always required. Although physicians can report 99211, CPT's intent with the code is to provide a mechanism to report services rendered by other individuals in the practice (such as a nurse or other clinical staff member). According to CPT, the staff member may communicate with the physician, but direct intervention by the physician is not required.

When to Use the Code No key components are required. Unlike other office visit E/M codes - such as 99212, which requires at least two of three key components (problem-focused history, problem- focused examination and straightforward medical decision making) - the documentation of a visit does not have any specific key-component requirements. Rather, the note just needs to include sufficient information to support the reason for the encounter and E/M service and any relevant history, physical assessment and plan of care. The date of service and the identity of the person providing the care should be noted along with any interaction with the supervising physician.

Examples of Common Uses  patient education  simple rechecks  medication reviews.  Some procedures can also appropriately be reported with this code. (review appendix C of the CPT manual) – also consider the following examples:

Procedure Examples of  An established patient comes to the office with complaints of burning when urinating and increased frequency of urinating. The nurse takes a focused history, reviews the medical record, discusses the situation with the physician who orders a urinalysis. The nurse then presents the findings to the physician, who writes a prescription for an antibiotic. The nurse communicates the instructions to the patient and documents the encounter in the medical record. In this example, and the appropriate laboratory code for the urinalysis should be reported because the E/M service is distinct from the lab service and appropriate for the evaluation of the patient's complaint.

Procedure Examples of  A patient comes to the office for a blood-pressure check. If the visit was scheduled at the request of the physician, should be reported. If the visit was prompted by the patient, the use of depends on whether there are clinical indications for the visit. For example, should not be reported for the stable patient who decides to come in for a blood-pressure check while in the area, because the physician did not order the service and there were no clinical indications, or medical necessity to validate the need for the visit. However, if the patient was experiencing problems (ex: dizziness or headache) and the nurse took additional history, checked the patient's blood pressure and talked with the physician, would be appropriate since clinical indications prompted the intervention.

Caution in Using  Some services are more appropriately reported with a CPT code other than 99211, because not every encounter is a “medical necessity”, that supports a separate visit code and because some patients may balk at the idea of being charged for some services (such as a blood-pressure check – co-pay’s apply) be cautious about establishing a practice of billing an E/M service with every staff encounter. A policy should be determined by the practice and communicated to all staff so that potential revenue for those services may be appropriately captured.

Caution in Using  Instead, use these guidelines and examples to determine the appropriate uses of Many Medicare carriers and other third-party payers periodically issue examples and guidelines regarding the proper use of certain codes, including this one. Staying abreast of these coding issues and being knowledgeable about these coding practices can ensure reimbursement for “provided services” and reduce potential audit liability to the practice.

630 South Church Street, Suite 300 Murfreesboro, TN Lori L. Hoyt Physician Practice Management Consultant (615)