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Find-A-Code Articles, Published 2021, September 28

When is it proper to bill nurse visits using 99211.

by   Christine Woolstenhulme, QMC QCC CMCS CPC CMRS Sep 28th, 2021 - Reviewed/Updated Aug 29th

When vaccines or injections are given in the office, coding can often get confusing; for example, is it correct to report a nurse visit using  99211  and an E/M office visit reporting  99202  ‑  99215  and include injection fees with the vaccine product? In addition, the reporting of evaluation and management (E/M) during the same visit where vaccines are administered is not always understood. The answer depends on whether the provider performs a medically necessary and significant, separately identifiable E/M visit, in addition to the immunization administration.

CMS states, when a separately identifiable E/M service (which meets a higher complexity level than CPT code  99211 ) is performed, in addition to drug administration services, you should report the appropriate E/M CPT code reported with modifier -25. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required.

It is incorrect to bill a  99211  when the provider provides an E/M service that meets a higher complexity level than CPT code  99211 , you must bill the higher complexity, and you cannot bill for two services in one day. 

Charging for Nurse Visits

There are times when it is appropriate to report for a nurse visit using CPT code  99211 . The  Incident-to rule  applies when reporting this code, and services provided must be documented as medically necessary services, including the clinical history, clinical exam, making a clinical decision, and physician supervision. 

• NOTE: A nurse visit is not paid if billed with a drug administration service such as chemotherapy or non-chemotherapy drug infusion code, including therapeutic or diagnostic injection codes. The reasoning is because diagnostic IV infusion or injection services typically require direct physician supervision, and using  99211 is reported by qualified healthcare professionals other than physicians.

08/29/2023 NOTE: (These CPT codes,90782, 90783, 90784, or 90788  were deleted in 2006, but still showing in CMS - Claims processing manual) When reporting CPT codes 90782, 90783, 90784, or 90788 , CPT code 99211  cannot be reported. In addition, it is improper billing to report a visit solely for an injection that meets the definition of the injection codes. 

When the only reason for the visit is for the patient to receive an injection, payment may be made only for the injection (if it is covered). An office visit using  99211 would not be warranted where the services rendered did not constitute a regular office visit and a part of the plan of care and not at the patient's request.

Unlike other E/M codes  99202 - 99205 , and 99212 - 99215 , time alone cannot be used when reporting  99211  when selecting the appropriate code level for E/M services. Effective January 1, 2021, time was removed as an available code-selection criterion. The typical time spent on this code is five minutes.  

Other visits billed with  99211

Several other visits may be reported using  99211 , and nurses are not the only staff that can report this code; medical Assistants and technicians are also included under non-physician.  

Covid-19 Testing

According to  CMS ; Physician offices can use CPT code  99211  when office clinical staff furnish assessment of symptoms and specimen collection for Covid-19 incident to the billing professionals services for both new and established patients. When the specimen collection is performed as part of another service or procedure, such as a higher-level visit furnished by the billing practitioner, that higher-level visit code should be billed. The specimen collection would not be separately payable.

Examples from CMS

The following are examples of when  CPT  99211  might be used:

• Office visit for an established patient for blood pressure check and medication monitoring and advice. History, blood pressure recording, medications, and advice are documented, and the record establishes the necessity for the patient's visit.
• Office visit for an established patient for return to work certificate and advice (if allowed to be by other than the physician). Exam and recommendation are noted, and the Return to Work Certificate is completed, copied, and placed in the record.
• Office visit for an established patient on regular immunotherapy who developed wheezing, rash, and swollen arm after the last injection. Possible dose adjustments are discussed with the physician, and an injection is given. History, exam, dosage, and follow-up instructions are recorded.
• Office visit for an established patient's periodic methotrexate injection. Monitoring Lab tests, query signs and symptoms, obtain vital signs, repeat testing, and injection advised. All this information is recorded and reviewed by the physician. (Note that in this circumstance, if  99211  is billed, the injection code is not separately billable). An office visit for an established patient with a new or concerning bruise is checked by the nurse (whether or not the patient is taking anticoagulants), and the patient is advised on how to care for the bruise and what to be concerned about, and, if on anticoagulants, continuing or changing current dosage is advised. History, exam, dosage, and instructions are recorded and reviewed by the physician.
• Office visit for an established patient with atrial fibrillation who is taking anticoagulants and has no complaints . The patient is queried by the nurse, vital signs are obtained, the patient is observed for bruises and other problems, the prothrombin time is obtained, the physician is advised of prothrombin time and medication dose, and medication is continued at present dose with follow up prothrombin time in one month recommended. History, vital signs, exam, prothrombin time, INR, dosage, physician's decision, and follow-up instructions are recorded.

References/Resources

About christine woolstenhulme, qmc qcc cmcs cpc cmrs.

Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code.  Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.

When is it Proper to Bill Nurse Visits using 99211. (2021, September 28). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/nurse-visits-and-injections-36866.html

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Who Can Report 99211?

Defining “nurse” for coding and reporting purposes, what are the documentation requirements for 99211, what is the current policy for reporting 99211, when is it appropriate to report 99211, what about commercial payer policies, clearing the confusion: billing “nurse” visits.

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American Academy of Pediatrics; Clearing the Confusion: Billing “Nurse” Visits. AAP Pediatric Coding Newsletter September 2005; 2005 (4): No Pagination Specified. 10.1542/pcco_book025_document001

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Questions continue to be raised about the appropriate billing of code 99211. Can this level of service be reported by a physician? Would it be appropriate to report a nurse visit when, for example, the nurse administers vaccines or an antibiotic, performs a strep test, obtains blood, reads a purified protein derivative (PPD), or performs a weight check?

The Current Procedural Terminology (CPT ® ) descriptor for code 99211 states, “Office or other outpatient visit for the evaluation and management [E/M] 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 or supervising these services.” The key to reporting this service? It must be medically necessary and require a face-to-face E/M service with supporting medical record documentation.

A physician typically does not report this level of E/M. Usually when the visit re-quires a face-to-face with the pediatrician, a minimum of straightforward medical decision making with a problem-focused history or examination is performed and documented. That level of visit would be reported as a level 2 visit (99212) as per CPT guidelines. Certainly a physician can report 99211 when providing a service if that physician feels it appropriate, but most often these types of visits are handled by nurses, allowing the pediatrician time to treat other patients.

The American Nurses Association recognizes that “non-advanced practice nonphysician providers” can diagnosis and/or assess patients, provided it is within the state’s scope of practice laws and meets incident to billing requirements.

When a nurse provides the 99211 visit, it is reported under the physician’s name and tax ID number as an incident to service. The incident to requirements as defined by the Centers for Medicare and Medicaid Services (CMS) are that services must be integral to the physician’s professional service, must be commonly rendered without charge or included in the physician’s bill, must be of a type commonly furnished in a physician office, and are furnished by auxiliary personnel under the physician’s direct supervision. Physician direct supervision is defined as the physician being physically present in the office suite (not in the patient’s room) and immediately available to provide assistance. The patient must be an established patient with the physician involved in the plan of care. Most nurse services are provided under an established protocol developed by the physician for the particular service and should be fully documented. The physician supervising the care must sign the chart entry.

The documentation requirements for 99211 differ from most of the E/M services provided by physicians. There are no required key components (history, physical examination, and medical decision making, or time if more than 50% of the total face-to-face time is spent counseling or coordinating care) and the typical time published in CPT for 99211 is 5 minutes. The American Academy of Pediatrics (AAP) encourages documenting the date of service and reason for the visit, a brief history of any significant problems evaluated or managed, any examination elements (eg, vital signs, appearance of a rash), a brief assessment and/or plan along with any counseling or patient education done, and signatures of the nurse and supervising physician. Documentation should clearly support the medical necessity of the visit.

Per CMS policy, CPT code 99211 cannot be billed solely for the purpose of administering an immunization or injection, collecting a specimen for a diagnostic test, checking vital signs that would not affect the patient’s care, or writing new or renewal prescriptions if no other assessment was performed. Reporting 99211 with these services requires that the service be separate, significant, and medically necessary. The American Medical Association also defines a reportable E/M service as being significant and separate from vaccine administration.

Immunization and drug administration CPT codes (including therapeutic or diagnostic infusions, chemotherapy administration services, and therapeutic, prophylactic, or diagnostic injections) include administrative and clinical services in their Resource-Based Relative Value Scale work values and cannot be billed with a nurse visit when the sole purpose of the visit is for the administration. In other words, these administration codes include taking vital signs, obtaining history related to the vaccine or medication, preparing and administering the medication or vaccine, observation for reactions, and medical record documentation.

The AAP has published a position paper with clear guidelines on billing 99211 with immunization administration. For more information and vignettes on the use of 99211 during immunization administration, visit the Member Center of the AAP Web site, http://www.aap.org/moc . Click on “Coding & RBRVS” on the right side of the page, and then click on “AAP Position Paper on Reporting 99211 with Immunization Administration.” An example of one vignette follows.

The basic premise for billing this level of visit is dependent on one thing—was the purpose of the visit to provide an E/M service of a significant and separate complaint or problem, or was the purpose to perform a procedure? Is it medically necessary, and will the documentation support the medical necessity?

An example of reporting 99211 with vaccine administration is a 4-month-old patient returning for a second hepatitis B vaccine. The vaccine was not given at her well visit 2 weeks earlier because of a high fever at the time of the visit. The nurse documents

The patient is here for a missed hepatitis vaccine and has had no fever for 7 days, is eating again, and seems to be well per father. Past vaccines have been well tolerated. Her temperature now is 98.7°F and she appears well. The risk and potential side effects of the hepatitis vaccine were discussed after the Vaccine Information Statement was given and the parent was informed of the correct dosage of an antipyretic should fever or fussiness occur afterward. The night call system was explained and the access number given.

K. Brooks, LPN/R. Dunn, MD (signatures/date)

This encounter would be reported as follows:

Note that modifier -25 has been appended to the E/M code to reflect that a significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service was provided. The use of a separate diagnosis code reported with 99211 also helps support the medical necessity of the visit.

Also note that the reported diagnosis is V67.59. This is correct reporting based on ICD-9-CM guidelines. Many payers, however, will not reimburse an E/M service with this code and will require you to report the “sick” diagnosis (in this case, fever). It is recommended that for these payers, you report the fever followed by V67.59.

Following are other examples for reporting 99211:

A child returns to the office for reading of a PPD administered at the last visit. The nurse documents

Patient here for reading of PPD administered on June 1, 2005. Results indicate 0 mm of induration. Discussed with parents signs/symptoms of disease.

Visit is reported as

An 8-year-old girl returns for weight check and blood pressure (BP) monitoring. The nurse documents

Patient here for weight and BP check. Last seen by Dr Jones 1 month ago. Weight 80 lb; BP 117/78. Doing fairly well with diet. Reviewed diet again with Sarah and Mom, stressed importance of increased exercise. To return for recheck in 1 month.

Note: No matter how much time was spent in counseling during this visit, only 99211 can be reported.

Remember that while most private payers follow CMS coding guidelines, they may establish their own policies for reporting and payment of nurse visits. It is important that every pediatric practice understand specific payer guidelines.

Most health plans will require a co-payment on any E/M service provided. If this is a requirement, you are mandated to collect this co-payment amount for 99211. Education is crucial to help parents understand the value of the service and that is it is a requirement of their health plan.

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Coding Physician Visits in Skilled Nursing Facilities/Nursing Facilities

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As of April 22, due to the COVID-19 public health emergency , CMS is waiving the requirement in 42 CFR 483.30 for physicians and non-physician practitioners to perform in-person visits for nursing home residents and allow visits to be conducted, as appropriate, via telehealth options. Prior to this, telehealth was only available for established patient visits.

Coding for Skilled Nursing Facility

• To be reported when the MD, DO, OD visits the patient in the Skilled Nursing Facility.
• Place of Service is 13.
• Initial Visit whether patient is new or established 99304, 99305, 99306
• Subsequent Skilled Nursing Facility visits performed in person or via telehealth: 99307, 99308, 99309, 99310

Coding for Nursing Home Visits

• To be reported when the MD, DO, OD visits the patient in a Nursing Home.
• Place of service is 13
• New Patient: 99324, 99325, 99326, 99327, 99328
• Established Patient: 99334, 99335, 99336, 99337
• Modifier -25

Note: When billing an intravitreal injection (or any minor surgery) the same day as an encounter, consider the definition of modifier -25 and although medically necessary, if the established patient exam is performed solely to confirm the need for the injection, the exam is not separately billable.

Coding for Home Visits

• To be reported when the MD, DO, OD visits the patient at their home.
• Place of service is 12
• New Patient: 99341, 99342, 99343, 99344, 99345
• Established Patient: 99347, 99348, 99349, 99350

View updates on telemedicine coding to use in your practice based on guidelines from CMS.

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Coding for E/M home visits changed this year. Here’s what you need to know

CPT has revised codes for at-home evaluation and management (E/M) services as of Jan. 1, 2023. Services to patients in a private residence (e.g., house or apartment) or temporary lodgings (e.g., hotel or shelter) are now combined with services in facilities where only minimal health care is provided (e.g., independent or assisted living) in these code families:

Home or residence E/M services, new patient

• 99341, straightforward medical decision making (MDM) or at least 15 minutes total time,

• 99342, low level MDM or at least 30 minutes total time,

• 99344 (code 99343 has been deleted), moderate level MDM or at least 60 minutes total time, 

• 99345, high level MDM or at least 75 minutes total time.

Home or residence services, established patient   

• 99347, straightforward MDM or at least 20 minutes total time,

• 99348, low level MDM or at least 30 minutes total time,

• 99349, moderate level MDM or at least 40 minutes total time,

• 99350, high level MDM or at least 60 minutes total time. 

Select these codes based on either your level of medical decision making or total time on the date of the encounter , similar to selecting codes for office visits . The E/M codes specific to domiciliary, rest home (e.g., boarding home), or custodial care (99324-99238, 99334-99337, 99339, and 99340) have been deleted, and the above codes should also be used in those settings.

When total time on the date of the encounter exceeds the threshold for code 99345 or 99350 by at least 15 minutes, you can add code 99417 to report prolonged services. The exception to this is for patients with Medicare. For those patients, report prolonged home or residence services to Medicare with code G0318 in addition to 99345 (requires total time ≥140 minutes) or 99350 (requires total time ≥110 minutes). Code G0318 is not limited to time on the date of the encounter, but includes any work within three days prior to the service or within seven days after.

Services provided in facilities where significant medical or psychiatric care is available (e.g., nursing facility, intermediate care facility for persons with intellectual disabilities, or psychiatric residential treatment facility) are reported with codes 99304-99310 .

— Cindy Hughes, CPC, CFPC

Posted on Jan. 19, 2023

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