Using CPT code 99211 can boost your practice’s revenue and improve documentation. The following guidelines can help you decide whether a service qualifies:
1. The patient must be established.
2. The provider-patient encounter must be face-to-face.
3. An E/M service must be provided. Generally, this means that the patient’s history is reviewed, a limited physical assessment is performed, or some degree of decision making occurs. If a clinical need cannot be substantiated, 99211 should not be reported. If another CPT code more accurately describes the service being provided, report it instead of 99211 (e.g., 36415 for a routine blood draw visit with a nurse).
4. The service must be separate from other services performed on the same day. Services considered part of another E/M service provided on the same day should not be reported with code 99211 (e.g., a nurse checks a patient’s vital signs prior to an encounter with the physician).
5. The presence of a physician is not always required. Although physicians can report 99211, CPT’s intent with the code is to provide a mechanism to report services rendered by other individuals in the practice. Medicare’s requirements are slightly different: The physician must have initiated the service as part of a continuing plan of care in which he or she will be an ongoing participant and must be in the office suite when the service is provided.
6. No key components are required. Unlike other office visit E/M codes – such as 99212, which requires at least two of three key components (problem-focused history, problem-focused examination, and straightforward medical decision making) – the documentation of a 99211 visit does not have any specific key-component requirements. 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 Centers for Medicare & Medicaid Services has proposed significant changes to the E/M documentation guidelines. Read more about the proposed rule at https://www.aafp.org/news/opinion/20180821presmsg-mpfs.html.
Adapted from "Understanding When to Use 99211."
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