David Stern, MD, CPC
Q. What is the code 99211?
A. The official description is as follows: “Office or other outpatient
visit for the evaluation and management of an
established patient, 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.”
This is a low-level Evaluation and Management (E/M) service.
The code requires a face-to-face patient encounter with a staff
member in the physician office, but a face-to-face encounter with
the physician is not required. Even though the services may be
performed by ancillary staff, it may be billed as if the physician
personally performed the service if all billing and payment
requirements for “incident-to” services are met.
To comply with incident-to requirements, documentation
must show either:
a link back to a previous visit with the physician (e.g.,
“Patient is seen on follow-up as directed by Dr. Smith”.
involvement of the physician directly in the visit (e.g.,
“History reviewed with Dr. Smith, who concurs”).
Q. What specific documentation is
required for 99211?
A. Unlike with other E/M services, the Centers for Medicare
and Medicaid Services (CMS) has not quantified specific
levels of history, physical exam, and complexity of medical decision
making needed to meet requirements for 99211. Nevertheless,
this should not be misunderstood to mean that there are
no documentation requirements for 99211.
Although CMS has intentionally left the requirements somewhat
vague, there are several documentation requirements in
addition to the already-mentioned incident-to requirements.
The record must document clinically relevant and necessary
exchange of information (historical information and/or physical
exam data) between provider (and/or ancillary staff) and patient.
Documentation should also demonstrate an influence on patient
care (medical decision-making, provision of patient education, etc.).
Documentation of services coded to substantiate the code 99211
must be legible and must include the identity and credentials of the
individual who provided the service.
Q. When is it appropriate to use 99211?
A. Generally, visits to ancillary staff that involve an element
of both evaluation and management may qualify for
99211. Examples of visits that qualify for 99211 include:
Blood pressure check that includes documentation of:
a clinical reason for checking blood pressure
blood pressure and other vital signs
current medications listed (with level of compliance noted)
the identity and credentials of the provider(s)
Recheck for cellulitis for a patient who has shown continuous
improvement over several days but requires repeated antibiotic
injection treatments.
Documentation may include:
a clinical reason for recheck
vital signs
history of pain, fever, or other symptoms
erythema, warmth, swelling, etc.
the injection of antibiotic including drug name, lot number,
and location of injection
the identity and credentials of the provider(s)
Recheck for medication refill, with documentation including:
a clinical reason for recheck
current medications and compliance
history of symptoms or their absence since previous visit
the identity and credentials of the provider(s).
Note: CPT codes, descriptions, and other data only are copyright 2007 American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).
Disclaimer: JUCM and the author provide this information for educational purposes only. The reader should not make any application of this information without consulting with the particular payors in question and/or obtaining appropriate legal advice.
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David Stern is a partner in Physicians Immediate Care, with nine urgent care centers in Illinois and Oklahoma, and chief executive officer of Practice Velocity (www.practicevelocity.com), a provider of charting, coding and billing software for urgent care. He may be contacted at
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