As a medical practice, it’s important to ensure that you are using Evaluation and Management (E/M) codes correctly. One code that has always been confusing is E/M code 99211; “the nurse visit code”. CPT defines this code as 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. Many physicians struggle with when – or why – to report this code. In this blog, we’ll discuss the correct use of code 99211 and how it can benefit your practice.

Firstly, it’s essential to understand that this code is not to be used when vitals were taken at the office prior to venipuncture; in this case, only 36415 should be reported.

The use of code 99211 can bring additional revenue to your medical practice; Medicare allowed amount in 2023 for 99211 is $25.83. Most facilities already provide this service but fail to capture those charges.

Guidelines for 99211:

• An E/M service must be provided: Since 99211 falls into the Evaluation & Management category, it can only be reported when one of the three main elements of an E/M service: an examination of the patient, history taking or review, and some degree of medical decision-making was done.
• The patient must be established: An established patient is a patient who has received any medical services from the provider or another provider of the same specialty and subspecialty in the same group practice within the last three years. Code 99211 cannot be reported for services provided to patients who are new to the physician or the practice.
• The encounter must be face-to-face: Code 99211 cannot be reported for services provided online or over the phone.
• The service must be medically necessary: Services provided must be clinically indicated by a healthcare professional and must be a part of their plan of care. Additionally, the E/M service must be separate from any other service provided that day and should have enough clinical evidence to support its need.
• No key components are required: 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.
• The presence of a physician is required: To report CPT 99211, payers require that the supervising physician or healthcare professional is in the office when the service is provided, but not necessarily in the same room.

Examples of a billable 99211

• If an established patient comes to the office complaining of urinary burning and frequency. The nurse takes a focused history, reviews the medical record, discusses with the physician the situation, and orders a urinalysis. The nurse then presents the results to the physician, who prescribes antibiotics. The nurse communicates to the patient and documents the encounter in the progress note. In this case, 99211 and the appropriate laboratory code for 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.
• If an established patient comes to the office for a blood pressure check that was scheduled at the request of the physician, 99211 should be reported. History, blood pressure recording, medications, and advice are documented, and the record establishes the necessity for the patient’s visit.
• If an established patient comes to the office for suture removal whose sutures were placed at a different practice, code 99211 could be reported, since there is no specific CPT codes for suture removal. However, 99211 would not be appropriate for the suture removal if the sutures were placed and removed at the same practice, because the code reported for placing the sutures would also include the removal.
• If an established patient comes to the office and the nurse performs a simple dressing change to assess and dress open wounds or other injuries. Code 99211 would be appropriate as long as the dressing change wasn’t performed as part of burn treatment or routine post-procedure care within the global period.

In essence, when reporting 99211, make sure the documentation includes anything the NPP did such as vitals, discussing current medications, or answering patient questions. Documentation should also include the reason for the visit and the diagnosis, along with any applicable orders or discussions the Non-Physician Provider (NPP) had with the physician about the patient.

It’s important to note that the use of code 99211 should be based on the specific circumstances of the patient’s visit and the services provided. If a patient’s visit requires more extensive evaluation or management, a higher-level E/M code may be more appropriate. Additionally, appropriate documentation should be maintained to support the level of service billed. By using this code appropriately, you can increase the efficiency of your practice and reduce the risk of audits or claims denials.

Insurance Billing Solutions is here to help your medical practice to remain compliant. Contact us today for more information about our medical billing services.