Answer 3 Questions to Enhance Your Nurse Code Reporting

Be on the safe side by following 99211's coding requirements.

If used correctly, 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician), otherwise known as the "nurse code," can certainly be a revenue boosting tool. Nurse your billing woes by answering these three medical billing and coding questions.

Question 1: Was the Provider of the Service On Site?

This refers to the "incident to" clause as defined by Medicare, which says: "Even though the 99211 code does not need the presence of the physician in the patient's room or a face-to-face encounter with the physician, the service would be done by face-to-face encounter with the physician's staff and ‘incident to' (meaning the physician must be in the office suite and immediately available) a physician's service."

In brief and for accurate medical billing and coding, your practice must document a face-to-face assessment by a dermatologist's staff and the rendering of a medical service that has an impact on the patient's care. The "incident to" clause stems from Medicare's prerequisite which states that the physician should at least be in the office when the service is delivered.

Why: Medicare considers these services to be an integral even though "incidental" part of the physician's professional service. However, for medical billing and coding accuracy, you can bill 99211 as "incident to" other health professionals like physician assistants or nurses.

Question 2: Was an E/M Service Provided?

It's necessary for you to meet 99211's criteria. In general, the provider should review the patient's history, carry out a limited assessment, or do some kind of decision making. A change in the medical regimen is not an AMA CPT prerequisite to bill 99211. Though, this may be needed by various payers and as such included in their coverage policies/provider education materials.

With any physician services, the E/M services reported by 99211 should always be medically necessary, and the ancillary staff must sufficiently document these services. Something which is as simple as a blood-pressure check with a review of meds can be billed with a 99211 (CPT states ‘presenting problem[s] is minimal'). In case there is a change in plan of care, then the MD should be involved, thus raising the E/M level.

Question 3: Was Service Rendered Face-to-Face?

Red flag: Phone calls with patients are not appropriate with the CPT codes 99211 face-to-face necessities. The dermatologist or his staff must talk to the patient in person. One of the chief purposes of 99211 is to offer a mechanism to report services rendered by other individuals in the practice (e.g., a nurse or other clinical staff member).

The staff member may consult with the dermatologist, however direct involvement of the dermatologist is not essential.

Medical Billing and Coding Update: Medicare has it a different way. Though the physician's presence is not needed at every single 99211 service involving a Medicare patient, the physician should have started the service as part of an on-going plan of care in which he or she will be an on-going participant.