Low-Level Code May Have High Misuse

It’s been called the “nurse visit” code, and also “the most abused code in the CPT book.”

Current Procedural Terminology (CPT) code 99211 is the lowest-level, established patient visit code. “It seems astonishing that a low-level code … could be considered in this way [most abused], but astonishing only until you consider two things,” writes Betsy Nicoletti in Auditing Physician Services, Second Edition. They are (1) the high volume of 99211 visits billed to third-party payers, and (2) “the propensity of medical practices to add 99211 when billing for another service by nursing staff.” 

Because the CPT code 99211 definition specifies that the service billed, “may not require the presence of a physician or other qualified health care professional,” some practices apply it to any service a nurse provides. But that’s not always correct.

Here is a quick checklist from Ms. Nicoletti.

To bill 99211: 

  • The service must be medically necessary for that patient on that date;
  • It must not be in lieu of billing another, more accurately described service;
  • The patient must be an established patient;
  • There must be a face-to-face service; 
  • The date of service and legible identity of the provider must be documented; and
  • For Medicare, the service must meet incident-to rules. 

Do not bill 99211: 

  • If all you did was provide an injection or draw blood;
  • For renewing a prescription;
  • For making phone calls;
  • For services performed solely as part of an office policy; or
  • If all the documentation for the service is on a flow sheet for another service. 

The full definition of CPT code 99211 is: 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) is minimal. Typically, five minutes are spent performing or supervising these services.

Auditing Physician Services: Verifying Accuracy in Physician Services and E/M Coding, Second Edition, is available in PDF format from the TMA Education Center. If you have questions about billing and coding or payer policies, contact TMA’s reimbursement specialists at paymentadvocacy@texmed.org for help, or call the TMA Knowledge Center at (800) 880-7955. For more in-depth help, turn to TMA Practice Consulting for a custom coding and documentation review, training session, or check-up.

Published Aug. 8, 2016

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Last Updated On

December 06, 2016

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