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Clarification for use of 99211 code

Use of 99211 Code

Taken from: Florida Medicare Part B Update Pages 17-18.

99211-Billing Issues

Florida Medicare has received inquiries from the provider community regarding medical record documentation that would support billing the Evaluation and Management (E/M) procedure code 99211 alone and/or with other billable services. Therefore, the following general documentation guidelines are being provided for clarification:

  • The E/M must be of an established patient.
  • According to the AMA’s Current Procedural Terminology (CPT), the E/M service may not require the presence of a physician. However, in order to qualify for Medicare payment, if someone other than the billing provider performs the service, all requirements of “Incident to” services must be met.

These include:

  • The services/supplies are an integral, although incidental, part of the physician’s/provider’s professional services.
  • The services/supplies are of a type that are commonly furnished in a physician’s/provider’s office or clinic.
  • The services/supplies are furnished under the physician’s/provider’s direct personal supervision. This means the physician/provider must be present in the immediate office suite and available to provide assistance and direction throughout the time the employee is providing the service.
  • The services/supplies are furnished by an individual who qualifies as an employee of the physician/provider.
  • The presenting problem(s) is usually minimal, and, typically, five minutes is spent providing the service. Please note, there must be a presenting problem documented. The documentation must demonstrate the reason for an E/M service on that particular date of service.
  • The medical record should indicate the nature of E/M service that occurred for the date of service being billed. If the service is being provided “Incident to,” the medical record should demonstrate that the service is an integral, although incidental, part of the physician’s professional service. The following clinical scenarios are meant to provide some general examples of documentation that would support billing procedure code 99211, and, is not an all-inclusive list:
  • A blood pressure (B/P) written down on the medical record does not demonstrate a presenting problem and need for an E/M service. The medical record should indicate why the patient came in for a B/P check (e.g., follow-up after medication adjustment, the previous note in the medical record documented elevated B/P and the provider wrote instructions for the patient to come in weekly for three weeks for B/P reevaluation, etc.).
  • A diabetic patient comes in for a monthly weight check related to an ongoing weight reduction plan for control of blood glucose levels. The medical record should document that the monthly weight check is an integral part of the patient’s plan of care and that some form of face-to-face E/M occurred either by the provider or “Incident to” (e.g., the weight is documented and the patient was questioned regarding appetite, any associated problems, etc.).
  • A patient comes in for a renewal of a prescribed medication. The medical record should demonstrate that the medication is part of the patient’s plan of care and that some form of face-to-face E/M occurred either by the provider or “Incident to” (e.g., prescription documented and instructions given to the patient regarding medication, side effects, etc.).
  • A patient comes in for E/M of his/her anticoagulation medication. The medical record should demonstrate that some form of face-to-face E/M occurred either by the provider or “Incident to” (e.g., the lab result is documented and a note made as to whether modification was made to the medication dosage).
  • When 99211 is billed on the same date of service as another billable service it must meet the requirements for billing the modifier 25 (Significant, Separately Identifiable Evaluation and Management). This modifier indicates, “the patient’s condition required a significant, separately identifiable E/M above and beyond the other service provided or beyond the usual pre- or postoperative care associated with the procedure.” The following clinical scenarios are meant to provide some general examples of instances regarding billing 99211 in addition to other billable services, and, is not an all inclusive list:
    • Billing 99211 in addition to chemotherapy administration codes (96400-96549). The administration of chemotherapy does not automatically justify billing a 99211 visit. The documentation must support that an E/M service was provided. The chemo administration code includes such things as the insertion of a catheter, set-up of the IV, administration of the medication, monitoring of adverse reactions during treatment. However, should a problem arise that requires a significant, separately identifiable E/M service, then the appropriate level E/M code should be reported in addition to the chemo. The following clinical example would support billing 99211 with modifier 25: The patient was questioned regarding any problems/side effects since the last visit and the notes indicate the patient is experiencing significant nausea, and weight loss has occurred. This is communicated to the physician and some form of patient E/M occurred (e.g., prescription for medication, patient education, diet change, etc.).
    • Billing 99211 in addition to a therapeutic, prophylactic or diagnostic injection (90782). If the patient came in for a routine injection(e.g., Vitamin B12) and no other services were provided, procedure code 90782 would be the appropriate code to bill. However, if the patient came in for a routine injection, and the patient’s condition required a significant, separately identifiable E/M above and beyond the injection, it would be appropriate to bill the appropriate E/M code with modifier 25. The following clinical example would support billing 99211 with modifier 25: The patient came in for routine B12 injection and complained of increased tingling in lower legs over the past few weeks. The office employee documented this complaint and informed the physician. The notes indicate that the patient was instructed to make a follow-up appointment with the physician for further evaluation.

Italicized and/or quoted material is excerpted from the American Medical Association Current Procedural Terminology. CPT codes, descriptions and other data only are copyrighted 2001 American Medical Association (or such other date of publication of CPT). All rights reserved. Applicable FARS/DFARS apply.

If you have any questions, please contact the Office of Compliance (Gainesville) at (352) 265-8359.

Webmaster athagan@ufl.edu, College of Medicine, Office of Physician Billing Compliance
Page created 10/9/09. Maintenanced 9/9/13.

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