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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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7 Resources for Nurse Practitioners to Decode Primary Care Billing and Coding

Home / Nurse Practitioner Articles / 7 Resources for Nurse Practitioners to Decode Primary Care Billing and Coding

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From insurance reimbursement and billing to coding and audits, these responsibilities can leave any healthcare provider with goosebumps – especially those who work in or own their own private practice. The most stressful part, in relation to insurance reimbursement, is that most healthcare providers like nurse practitioners are not formally trained in billing and coding and work in a clinical setting or facility with no certified billing and coding specialists. Luckily, there are a wide variety of resources available to help decode this unfamiliar territory.

Coding Basics

Accurate coding is critical for insurance reimbursement, succinct documentation, and identifying clinical care gaps. The Healthcare Common Procedure Coding System (HCPCS) codes and International Classification of Diseases, 10th Revision (ICD-10) codes serve as the building blocks of medical coding.

• Category I: Common procedures
• Category II: Performance measurements
• Category III: Emerging technologies
• HCPCS Level II codes: These codes are used to describe products, supplies, and services provided during an encounter.
• ICD-10 codes: These codes are used to describe the reason for a patient encounter or outline a patient's characteristics, and are essential for identifying common diagnoses in a medical practice. They notify the insurance payer of the medical necessity of the visit.

Evaluation/Management Coding

Evaluation/Management (E/M) coding is the core of healthcare billing and insurance reimbursement. Understanding E/M coding can help maximize the insurance reimbursement of a practice and reduce stress levels during audits. These codes are based on several factors :

• The patient's history
• The patient's physical exam
• The provider's medical decision making
• The appointment time, specifically if the provider spent 50% of the visit coordinating care or counseling

There are different levels for the aforementioned factors, which decipher which E/M code to use.

• Problem-focused
• Expanded problem-focused
• Comprehensive
• Straightforward
• Low complexity
• Moderate complexity
• High complexity

The level of complexity related to medical decision making depends on the number of diagnoses and management options, the complexity of the patient data that was reviewed, and the risk of complications or morbidity/mortality.

Transition of Care Billing and Coding

Transition of care visits are an efficient way to support the continuity of care after a patient is discharged from a skilled nursing facility/nursing facility, long-term acute care hospital, rehabilitation hospital, acute care hospital, or observation stay in a hospital. A transition of care visit can only be billed one time per patient in a 30-day timeframe, and can be billed for both new and established patients at a particular clinic.

Transition of care visits can be billed using two different codes.

• 99495- This code can only be used if the patient has been contacted within two business days of their discharge, the medical decision making is of moderate complexity, and there is an in-person clinic visit within 14 days of the discharge.
• 99496- This code is used if the patient has been contacted within two business days of their discharge, the medical decision making is of high complexity, and there is an in-person clinic visit within seven days of the discharge.

Medicare Wellness Coding and Billing

Medicare wellness exams go beyond a typical annual adult wellness examination. In addition to focusing on a patient's wellness, these exams involve a thorough screening centered around disease prevention. The exam also takes a more comprehensive look at the patient's vital signs, medical/family history, and health risk assessments including their emotional and psychological well-being to develop a personalized prevention plan. Many types of healthcare providers can complete these wellness exams, including:

• Physician assistants
• Nurse practitioners
• Clinical nurse specialists
• Registered dietitians
• A team of medical professionals with an overseeing physician

RELATED: Complete Guide to the Adult-Gerontology Nurse Practitioner Specialty

Pediatric Coding and Billing

Accurate coding for the pediatric population is similar to the process for the adult population with several additional considerations including behavior screenings, developmental screenings, and vaccine administration . Another complication is that not all of these screenings and vaccines are completed at every age. Each well child examination typically has different screenings and different vaccine administrations or they may not have any vaccines at all. That's why it is important to follow the recommendations of Bright Futures, which establishes guidelines that insurances follow.

RELATED: Complete Guide to the Pediatric Nurse Practitioner Specialty

Initially, the billing and coding world can be daunting and confusing. Luckily, there are a variety of resources available to help providers make sense of this information. In addition to online resources, there are several textbooks and conferences that can strengthen a provider's knowledge of accurate billing and coding. Accessing the right resources can help providers boost their understanding, which leads to more efficient documentation, increased reimbursement, and decreased stress during chart audits.

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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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CPT Code 99211 Nurse Visits | CPT Coding Tips

Q: “Can someone please discuss CPT Code 99211?

A: Why, sure, we can. Unlike Alicia, I wanted Chandra to do my answer sheet because I always have best intentions but normally the Thursday of the webinar we’re all running around and I’m like, “Last minute Laureen,” and it’s a very bad habit. At any rate, answer prepared by Chandra, presented by Laureen but it’s a real quickie so we’ll get right to your chat questions.

First of all, what’s the definition of 99211? We’ve got our new patient codes and we’ve got our established patient codes for evaluation and management. The 99211 is the first code for established outpatient but it’s very unique. It doesn’t have the common three bullets – history, exam and medical decision making – like you see with the other codes and it’s often referred to as the nurse visit code.

VIDEO: CPT Code 99211 Nurse Visits | CPT Coding Tips

Here’s the definition: 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 healthcare professional. Usually the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services. So, the not requiring a physician is why they call it a nurse visit code.

Generally, it’s often ancillary nursing staff that’s going to be providing the services during the encounters and it is an E/M service, so there is some HEM going on – history, exam, medical decision making. But CPT doesn’t specify which areas or the amount like they do with other codes where they have discrete levels of history, exam and medical decision making.

Medicare places further restrictions on reporting 99211 by lumping it into the types of services typically performed “incident to” the physician’s services. What that means is under the “incident to” practice the physician must have established the plan. So, it’s not the nurses just taking over and treating the patient. The physician has established the plan and the nurses during follow-up in relation to that. So, that’s what that “incident to” is talking about and there has to be direct supervision. It means the physician has to be immediately available in the office suite to take over care should the need arise.

There must be a documented need for the services provided and the ancillary staff may not address any new problems or change any portion of the plan of care and order for the service to be considered “incident to.” The physician must also periodically see the patient – that would be nice. Some insurance carriers further specify this by defining “periodically” as at least every third visit.

So, if a patient is coming in for a routine thing that the doctor is aware of, he has established the plan, he’d say, “OK, poke your head in every third visit just to make sure everything’s going well.”

The types of services typically provided during these encounters are evaluation and management services considered minor in nature that do not meet any other code definition, such as blood pressure checks, weight checks, etc.

Some providers feel it is appropriate to report a nurse visit (99211) in addition to venipunctures, immunizations, etc. However, most insurance carriers will deny these… they will bundle them together. The reason is, for immunizations, the provider is already receiving payment for the E/M portion of the service… or, in the case of the venipuncture, the bundle the minimal E/M service provided into the payment for the venipuncture… They don’t want you to double dip.

For more information on CPT® code 99211 and nurse visits, here are a few articles and references that may be helpful. Again, advantage of being in the Replay Club, you get all these links and benefits of our research. That was my quickie question on nurse visits and thank you Chandra for doing that nice answer sheet for us.

Related CPT Code 99211 Nurse Visits Posts:

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2 thoughts on “CPT Code 99211 Nurse Visits | CPT Coding Tips”

IS CONDUCTING A BIOMETRIC WELLNESS SCREENING BY A NURSE (AS A NURSE VISIT IN AN OUTPT. CLINIC )CAN BE BILLED UNDER 99211

Unfortunately, this request is outside the scope of help we can provide on the blog. We recommend submitting it for consideration at our Topic Requests page: https://www.cco.us/topic-request/

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You can boost revenue by learning when to compliantly use this code. Stop losing money today with 3 strategies that will help you inject more nonphysician work reimbursement to your practice without added scrutiny.

Expand CPT Code 99211 Eligibility to MAs, LPNs, and Other Staff

CPT code 99211 is often called the nurse visit code. But it’s not just for nurses! Many of your practice employees can provide the service. They must be qualified to evaluate and meet the patient’s care needs in a limited capacity. That means, you can bill 99211 for a medically necessary, face-to-face established patient service performed by a healthcare professional including a:

• Medical Assistant (MA)
• Certified Nurse Assistant (CNA)
• Licensed Practicing Nurse (LPN)
• Registered Nurse (RN)
• Nurse Practitioner (NP)
• Physician Assistant (PA)
• Physician (MD).

Prevent Denials, Prove Medical Necessity for CPT Code 99211

One of the big reasons CPT 99211 is denied is because clinicians don’t meet the medical necessity requirement. In order to bill code 99211 you must indicate that the service is medically necessary. This isn’t as daunting as it seems.

In determining if the visit meets the medical necessity requirement, ask yourself this question: Is the purpose of the visit to provide patient care that influences a physician’s medical decision making or needed patient education? To prove medical necessity – and overturn a denial, you’ll need to keep detailed documentation, including:

• Reason for the “nurse visit” via a plan of care
• Patient’s diagnosis, dose, and recent labs
• Today’s presentation/health status/new education
• Credentials of the face-to-face staff and provider.

Add $15 Revenue for Needed Check-Ups, Abnormal Results, and More

Visits billable by CPT 99211 are short, and you are probably already providing many of these services for your patients. Don’t exclude routine services from being eligible for the nurse visit code. You can use the code for routine services that are medically necessary such as the following examples:

• A scheduled follow-up visit for weight check for a patient recently placed on a new medication known to cause weight gain
• A blood pressure evaluation for an established patient whose physician requested a follow-up visit to check blood pressure
• Discussion with patient in-person following abnormal laboratory tests
• Suture removal following placement by a different physician/physician group
• Diabetic counseling that is non repetitive
• Dressing change for an abrasion/injury

The bottom line is if you aren’t using CPT 99211 for your non-physician work, you are giving their time away. This is where nationally recognized expert coder and educator Kim Garner Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO. In her online training CPT Code 99211: Get $15 Per Patient on Nonphysician Work , she will tell you precisely how to accurately use code 99211, and help you get paid for more visits.

Check out our Coding and Billing Playlist on YouTube for the latest expert advice, and subscribe to our YouTube channel for step-by-step guidance!

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Corporate Access: Select this option to receive online, on-demand access to your training across each of your locations. Setup will be initiated by our account team within 48 hours of your enrollment and can be utilized by your entire team.

You and your entire team, at all your locations, can attend as many live and view as many recorded trainings as you like for 12 months.

You and your team, in one single location, can attend as many live and view as many recorded trainings as you like for 12 months.

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June 28, 2024

Non-Physician Practitioners in Nursing Facilities

Find additional information about nursing facility services   Everyday Coding .

Can a physician assistant see patients in a nursing facility without a physician signing each encounter? How do we bill this? Can we do wellness visits in a nursing facility?

• A physician assistant or an advanced practice registered nurse  may see patients independently in a nursing facility but must bill under their own provider number. Beginning 1-1-2022, visits that are not mandated as physician services may be reported as shared services between a physician and a non-physician practitioner.
• Mandated visits: Only a physician may bill the initial nursing facility visits 99304-99306 in a skilled nursing facility or nursing facility.  (There is an exception to this in a nursing facility who is not employed by the facility). Sometimes, the PA/NP sees the patient at an earlier date than the physician, who comes and does the admission. In that case, the PA/NP bills a subsequent visit, even though the initial has not been billed. This is a Medicare rule.
• I am not aware of any restrictions against billing wellness visits in the nursing facility, provided it is appropriate to do a preventive plan for the patient.

Here  is a link to the MedLearn matters article . It discusses frequency of mandated physician visits.

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Last revised June 27, 2024 - Betsy Nicoletti Tags: medicare incident-to and shared services

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0222-Non-Physician Billed Without Correct Assistant at Surgery Modifier: Incorrect Coding

Description

Assistant at surgery services by non-physician providers (PA, NP, or CNS), are reimbursed at 85 percent of 16 percent (i.e., 13.6 percent) of the Medicare Physician Fee Schedule Data Base amount. Modifier "AS" is used for assistant at surgery services provided by a physician's assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). Assistant at surgery claims billed by non-physician practitioners without modifier AS, will be corrected, adding modifier AS, repricing the claim.

Affected Code(s)

CPT code range 10021 through 69990 with assistant at surgery indicator of “0” or “2” 

Applicable Policy References

1.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 2.    Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3.    Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(a)(1)(O)- Payment of Benefits 4.    42 Code of Federal Regulations (CFR) §405.929- Post-Payment Review 5.    42 Code of Federal Regulations (CFR) §405.930- Failure to Respond to Additional Documentation Request 6.    42 Code of Federal Regulations (CFR) §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 7.    42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening  8.    42 Code of Federal Regulations (CFR) §414.4- Payment for Part B Medical and Other Medical Services 9.    42 Code of Federal Regulations (CFR) §414.40- Coding and Ancillary Policies 10.    Medicare Benefit Policy Manual Chapter 15 §200 - Nurse Practitioner (NP) Services 11.    Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioner, §20.4.3 12.    Medicare Claims Processing Manual Chapter 12- Physician Practitioner Billing, § 100.1.7.B. 13.    Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioner, §110.2 - Limitations for Assistant-at-Surgery Services Furnished by Physician Assistants 14.    Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioner, §120 - Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) Services 15.    Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 16.    American Medical Association. “Modifiers Used with Surgical Procedures”, CPT Assistant, Fall 1992, page 15.  17.    American Medical Association. "A Closer Look at the Use of Surgical Modifiers" CPT Assistant, March 1996: 8. 18.    American Medical Association Current Procedural Terminology (CPT) Codebook 19.    Medicare Physician Fee Schedule (MPFS) Physician Fee Schedule | CMS 20.    AMA CPT Codebook

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KENT J. MOORE

Fam Pract Manag. 2002;9(9):23

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Cpt codes for np visits, coding prolotherapy.

Editor’s note : While this department attempts to provide accurate information and useful advice, third-party payers may not accept the coding and documentation recommended. You should refer to the current CPT and ICD-9 manuals and the “Documentation Guidelines for Evaluation and Management Services” for the most detailed and up-to-date information.

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Send questions and comments to  [email protected] , or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.

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