Level-one” office visits may be the simplest of patient encounters, but when it comes to coding and documentation, they are widely misunderstood. More often than not, we tend to forget to bill 99211 for nursing visits and we undercode physician visits. One of the key problems, of course, is that the rules for coding and documentation are clear as mud, while the threat of audit is clear as day. The revised revised documentation guidelines, which are at least a year away from being implemented, may help the situation. But until then, family physicians can do better by reacquainting themselves with the most effective use of level-one evaluation and management (E/M) office visit codes.
According to the CPT manual, a 99211 is an office or other outpatient visit “that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services.” Unlike the rest of the office visit codes, 99211 does not have any documentation requirements for the history, physical exam or complexity of medical decision making. The nature of the presenting problem need be only “minimal,” such as monthly B-12 injections, suture removal, dressing changes, allergy injections with observation by a nurse, and peak flow meter instruction. (For more examples, see Appendix D of the CPT manual.)
Physicians generally should not use a 99211 code for their own services, but it may be appropriate for office services performed by a nurse.
To support the 99211 code for a nursing visit, a practice must have sufficient documentation.
If physicians use code 99201 regularly, they are likely undervaluing or under-documenting their services.
None of these visits requires the presence of a physician in the exam room (although the physician should be on the premises). In fact, as a rule of thumb, a physician should not code a 99211. What these visits do require is supporting documentation, so if you plan to charge for nurses' visits, you need to train your nurses to provide very basic medical documentation. I have found the most successful method for achieving adequate and consistent documentation from nurses is to make simple, check-box-driven forms, which guide nurses' decision making, protect you from litigation and give you the clinical data you would want yourself. (For examples of flow sheets that can assist nurses in documentation, see "Documenation help.")
Nurse charting for 99211 visits can be minimized and made more efficient by moving it almost entirely to flow sheets, such as the two available for download below. Longer notes, such as involved phone messages, can be documented in the progress note section of the chart to avoid filling up the flow sheet with narrative information. Nursing data need not be repeated in the progress note.
In the flow sheet for depo-progesterone injections ( Download in PDF format), the idea is, first, to collect the data needed to protect the patient from iatrogenic injury; second, to drive effective billing; and third, to minimize the effort needed for adequate documentation.
The vital signs flow sheet ( Download in PDF format) not only improves nurses' documentation but improves physician efficiency as well by allowing for rapid review of vital signs, past office visits, routine health care and medications. To inform the physician of a chief complaint, the nurse can simply attach a sticky note to the front of the chart. Scan the sample vital signs flow sheet and see if you can get a feel for this patient without reading the progress notes.
Note that, in our practice, we highlight no-show appointments and narcotic/benzodiazepine prescriptions in green and yellow, respectively. We have found that these features alone make the form worthwhile.
If you are not sure it is worth the effort to bill for a 99211, consider that a nursing visit for a depo-progesterone shot can generate a charge of approximately $150 (nursing visit 99211=$30, Depo-Provera 150 mg J1055=$90, urine pregnancy test 81025=$38), which even after insurer discounts is a significant amount. In my office, before we standardized nursing documentation and billing, we failed to capture approximately $4,000 per year for various portions of the nursing visit for depo-progesterone shots alone. The cost to standardize nursing documentation is minimal: a few copies of a form per year. The nurses spend no more time charting and are less confused about what they should be doing.
One word of caution about 99211: You can't bill for the administration of an injectable medication (90782) or for the administration of an immunization (90471, 90472) and a nursing visit at the same time. You can either bill for the 99211 plus the medications or bill for the injection plus the medications. When the nurse must make an evaluation of the patient (e.g., when giving a depo-progesterone shot, the nurse must consider, “might the patient be pregnant?”), then our practice uses the 99211. If the nurse must only give an injection, we use the injection codes.
In general, of the “new patient” codes, 99201 should be used only slightly less frequently than 99205. The goal is not to game the system and upcode, but if you find yourself using 99201 regularly, consider auditing your own billing and documentation practices. You will most likely find that you are either undervaluing your services or underdocumenting.
The 99201 code has more specific requirements than 99211 when it comes to elements of the history, physical and medical decision making. (See the table below, for the minimum required elements.) In addition, 99201 is not to be used for nursing visits, as the physician needs to see the patient and establish a care plan before nurses' visits can be billed.
Examples of typical 99201-type office visits from the CPT manual include an out-of-town patient needing refills on an NSAID, a topical preparation or an antihistamine for allergies. For documentation, remember to record a chief complaint, one element from the HPI and one physical exam bullet, and specify a diagnosis and plan.
99201 quick reference
Unlike code 99211, which has no specific documentation requirements, code 99201 for the evaluation and management of a new patient requires a problem-focused history, a problem-focused examination and straightforward decision making, as outlined in the table at right.
|Key components (need all three)||Elements||Minimum requirements|
|Problem-focused exam||Body areas/organ systems||1|
|Straightforward medical decision making (need at least two)||Diagnoses/management options||1 point (minimal)|
|Amount/complexity of data||0-1 point (minimal or none)|
When it comes to level-one office visits, three general rules should keep you on track:
Don't forget to bill for the nurse's time and expertise by using the 99211 code.
Use check-box forms to drive adequate documentation, to achieve consistency between nurses and to capture all appropriate fees.
Consider the use of a 99211 or 99201 for a physician visit as a red flag indicating potential undercoding.
If you are tempted to downcode for your poorer patients, remember that you will be committing fraud by billing one group of patients differently from another. Medicare gets very upset about this. The best way to help your patients who are less able to pay is to use the correct billing codes and documentation but use financial hardship forms to adjust their bills or set up reasonable payment schedules.
Proper coding and documentation is crucial to the success of any medical practice. If you spend a little time making sure you and your staff understand level-one visits, you may find that it enhances your practice's bottom line and protects you from legal trouble.