99211 Coding Quiz: Can You Identify Which of These Quick-Visit Services Qualify for 99211?

Hint: You can't automatically tack 99211 on to every service just because the nurse was present.

Most practices agree that 99211 is a ubiquitous code, reported nearly every day for visits ranging from blood pressure checks to medication updates. But the so-called "nurse visit" code may not always be appropriate. Many MACs are scrutinizing these claims and targeting them as "areas of concern," as WPS Medicare did this past April. Check out these common clinical scenarios and determine whether 99211 is appropriate for the circumstances.

Know Whether 99211 Applies to X-Rays

Question 1: A patient comes to see the physician for a leg problem. The staff performs x-rays and then the patient waits in the exam room for the doctor, but gets a call and has to leave before she actually sees the physician. Does 99211 apply to this visit?

Answer 1: "What is unanswered is was the x-ray ordered by the doctor?" asks Ruby Woodward, BSN, ACS-OR, coding and research specialist at Twin Cities Orthopedics in St. Louis Park, Minn. "If the physician ordered and read it, bill the x-ray unmodified. If the physician did not order the x-ray, then nothing can be billed."

In short, Woodward says, you cannot report 99211 unless an actual evaluation and management service was provided.

Will 99211 Cover Vaccines?

Question 2: A patient presents for vaccines only. The nurse administers two vaccines and the patient leaves. Should you report 99211 with the vaccine administration codes?

Answer 2: Not as a rule, no. If the nurse simply administers a vaccine and the patient leaves, the nurse most likely has not met the criteria for billing 99211. If, however, the nurse spends a lot of time counseling the patient or the patient has other diagnoses that the nurse goes over, then 99211 might be appropriate.

In some cases, depending on the CCI edits for the specific vaccine codes you're using, you may need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99211.

In black and white: "Services billed to Medicare under CPT code 99211 must be reasonable and necessary for the diagnosis and treatment of an illness or injury," says a policy on 99211 written by Part B MAC WPS Medicare.

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Part B Revenue Booster: Say Goodbye to X-Ray Denials With These Simple Tips

Palmetto providers: Add this 'history of' code to the list of covered conditions.

If you provide X-ray services, consider this: A chest X-ray's global fee is only $25 or so. Multiply that $25 by the number of services you perform, however, and you'll quickly see how getting these claims right is important to your practice's financial health.

Below, you'll find essential information for 71010 (Radiologic examination, chest; single view, frontal) and 71020 (Radiologic examination, chest, 2 views, frontal and lateral), including example services, typical supporting diagnosis codes, and advice on avoiding the most common causes of audit-related denials.

A tip to start: Codes 71010 and 71020 have separate professional and technical components under the Medicare physician fee schedule. So if you're reporting only the professional service, you should append modifier 26 (Professional component). To report the technical component only, append TC (Technical component). If you're reporting the global service (both professional and technical components), you shouldn't append modifier 26 or TC.

Boost Your X-Ray Skills by Understanding Views

The key element distinguishing 71010 from 71020 is that the first represents a single "frontal" view and the second represents two views, "frontal and lateral."

71010: The documentation for a 71010 service may refer to an "AP view," says Alice Wonderchek, CPC, billing and coding specialist with Ohio-based Radisphere National Radiology Group. AP stands for anteriorposterior, meaning the X-rays pass from the anterior (front) to the posterior (back) of the patient.

You also may see reference to a "PA view" (posterioranterior), in which the X-rays pass from the back to the front of the patient. The AP view can be more difficult to interpret than a PA view because of quality issues andthe way the heart appears enlarged on an AP view. As a result, the PA view usually is preferred over the AP view.

You typically will see an AP view when the patient cannot stand for the imaging service. As a result, another term you'll often see connected to 71010 services is "portable," meaning the tech takes the X-ray using a portable machine. You may see this particularly for services performed at bedside, Wonderchek says.

Example: A patient exhibits decreased breath sounds and low oxygen levels. The physician orders a portable AP chest X-ray to be performed at the patient's bedside. You should report 71010 for the single-view X-ray.

71020: You may see a 71020 service referred to as a "PA & Lat," Wonderchek says. The abbreviation refers to the PA (posterior-anterior) view and the Lat (lateral) view. Lateral means "side." Generally, the tech will take a left lateral X-ray, meaning the patient's left side is closer to the film than the right side is. But the physician may ask for a right lateral X-ray instead.

Example: A patient with a history of lung cancer presents complaining of fever and shortness of breath. Her physician orders PA and lateral X-ray imaging. This service merits code 71020.

Whittle Down the List of Likely Diagnoses

Physicians order chest X-rays for a wide variety of reasons. The potential exam findings also add up to a long list. Consequently, there are many ICD-9 codes that may apply to a chest X-ray claim.

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ICD-10 Preparation: Not Planning to Transition to ICD-10 as of Oct. 1, 2013? You Might Be Liable to Face Millions in Fines, CMS Reps Say

Plus: CMS officials are considering how to handle dates of service that span the pre- and post-ICD-10 implementation dates.

If you think the ICD-10 codes won't apply to your Medicare claims as of Oct. 1, 2013, CMS has news for you—not only will your claims be denied if you continue to submit ICD-9 codes to Medicare after that date, but you could face fines. CMS representatives shed light on this and several other issues during the agency's May 18 "ICD-10 National Provider Teleconference," and we've broken down the five FAQs that best apply to Part B practices.

Question 1: How will CMS handle claims that span from before Oct. 1, 2013 through dates after Oct. 1, 2013? Should the practitioner use ICD-9 or ICD-10 codes for these claims?

Answer: CMS is mulling how to handle this situation, but hasn't yet arrived at a firm decision. "We are getting very close to finalizing our decision for all claim types, including professional claims, supplier claims, and the various types of institutional claims," said CMS's Sarah Shirey-Losso during the call. "Some claims will continue to use the discharge date, some will use the ‘from' date, and some may be required to be split," she said.

Stay tuned: CMS is currently working on a final decision, which the agency will issue in a "Change Request" document this summer.

Date of service issue: If, however, you submit a claim for a single date of service, you'll submit ICD-9 codes for dates of service through Sept. 30, 2013, and ICD-10 codes for dates of service Oct. 1, 2013 and thereafter. For instance: If you send in a claim on Oct. 15, 2013, but the date of service is Sept. 1, 2013, you'll still use ICD-9 codes.

Question 2: Will workers' compensation insurers still use ICD-9, even after the rest of the industry transitions to ICD-10 after Oct. 1, 2013?

Answer: The answer to that is unclear, but CMS has heard murmurs that workers' comp. insurers will switch over to ICD-10.

"We've heard anecdotally that even though they're not required to transition to ICD-10, that many of them are planning to, just because it's more practical to do so and they see that it's the way the rest of the industry is going," said CMS's Denise Buenning, MsM, during the call.

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