Friday, July 22, 2016

CPT code 99211 - Billing Guide documentation

Procedure code and description

99211 - Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.

average fee amount - $20 - $30

For code 99211, the office or outpatient visit for the evaluation and management of an established patient may not require the presence of a physician or other  qualified health care professional.

Appropriate Use of Procedure  Code 99211

Because the appropriate use of Procedure  code 99211 is often confusing, we offer the following guidelines. According to the Procedure  Code Book, 99211 is intended for “an office or other outpatient visit for the evaluation and management of an
established patient that may not require the presence of a physician.” The key points to remember regarding 99211 are:

• The service must be for evaluation and management (E&M).

• The patient must be established, not new

• The service must be separated from other services performed on the same day.

• The provider-patient encounter must be face-to-face, not via telephone.

Code 99211 will be accepted only when documentation shows that services meet the minimum requirements for an E&M visit. For example, if the patient receives only a blood pressure check or has blood drawn, 99211 would not be appropriate. All E&M office visits follow the member’s office visit benefit; therefore, if another Procedure  code more accurately describes the service, that code should be reported instead  of 99211.

Examples of office/clinic visits generally billable using 99211:

• Patient recently placed on a new medication which causes weight gain. A follow-up visit is scheduled for weight check.

• A blood pressure evaluation for an established patient whose physician requested a follow-up visit to check blood pressure

• Refilling medication for a patient whose prescription has run out; however, patient must be present in office suite and physically seen by the provider

• Discussion with patient in-person following laboratory tests results that indicate the need to adjust medications or repeat order of tests

• Suture removal following placement by a different physician/physician group

• Visit for instructions/patient education on how to use a peak flow meter and other devices

• Diabetic counseling

• Dressing change for an abrasion/injury

Examples of services generally not billable using 99211:

• Blood draw only—should be billed using Proceure  36415 or 36416

• Laboratory tests—the lab performing the test should bill the appropriate codes

• Monitoring of cardiology tests, such as thallium stress tests, where such monitoring is inherent in the performance of the

• Injection of therapeutic and/or diagnostic medication—use Proceure  drug administration code and drug supply code (J code). Note: Part D drugs include the administration fee and must be billed directly to Medicare plan.

• Vaccinations/Immunizations—bill immunization Proceure  code (e.g., Flu 90658) and administration Proceure  code only (e.g., 90471)

Here’s a tip for billing code 99211: the presenting problem or problems should be minimal. Typically, five minutes are spent performing or supervising services such as blood pressure checks.

 Medicare will pay for medically necessary office/outpatient visits billed on the same day as a drug administration service with modifier -25 when the modifier indicates that a separately identifiable evaluation and management (E/M) service was performed that meets a higher complexity level of care than a service represented by Procedure code 99211

Carriers must advise physicians that Procedure code 99211 cannot be paid if it is billed with a drug administration service such as a chemotherapy or non-chemotherapy drug infusion service (effective January 1, 2004). This drug administration policy was expanded in the Physician Fee Schedule Final Rule, November 14, 2004, to also include a therapeutic or diagnostic injection code (effective January 1, 2005). Therefore, when a medically necessary, significant, and separately identifiable E/M service (which meets a higher complexity level than Procedure code 99211) is performed, in addition to one of these drug administration services, the appropriate E/M Procedure code should be reported with modifier -25. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required.

commercial insurance policy billing with Injection codes

Procedure 99211: E/M service code 99211 will not be reimbursed when submitted with a diagnostic or therapeutic Injection code, with or without modifier 25. This very low service level code does not meet the requirement for "significant" as defined by Procedure, and therefore should not be submitted in addition to the procedure code for the injection.

Will Oxford separately reimburse for an office E/M service when provided in other than POS 19, 21, 22, 23, 24, 26, 51, 52, and 61 if a significant, separately identifiable E/M service is performed in addition to the therapeutic or diagnostic Injection given on the same date of service by the Same Individual Physician or Other Health Care Professional?

A: Yes, Oxford will separately reimburse for an E/M service (other than Procedure 99211) unrelated to the physician work associated with the Injection service (Procedure 96372-96379) when reported with a modifier 25. Refer to Q&A #2 for a description of the physician work typically included in the allowance for the therapeutic and diagnostic Injection service. When an E/M service and an Injection or Infusion service are submitted for the same enrollee on the same date of service, there is a presumption that the E/M service is part of the procedure unless the physician identifies the E/M service as a separately identifiable service.

Example: The following example describes an E/M service that is separately identifiable from a therapeutic and diagnostic Injection: A physician evaluates a patient’s symptoms, diagnoses a serious streptococcal infection, and treats with injectable penicillin. The diagnostic process is separately identifiable from the process of the injection. The E/M service (other than Procedure code 99211) should be reported with modifier 25 and is reimbursed separately from the therapeutic Injection code and the drug code for the penicillin.

Documentation Requirements for Procedure Code 99211

Procedure code 99211 is used to report a low-level Evaluation and Management (E/M) service. The Procedure book defines code 99211 as:

“Office or other outpatient visits 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, 5 minutes are spent performing or supervising these services.”

Code 99211 requires a face-to-face patient encounter; however, when billed as an “incident to” service, the physician’s service may be performed by ancillary staff and billed as if the physician personally performed the service. For such instances, all billing and payment requirements for “incident to” services must be met.

As with all services billed to Medicare, code 99211 services must be reasonable and necessary for the diagnosis or treatment of an illness or injury. Unlike the other E/M Procedure codes, the Procedure book does not specify completion of particular levels of work for code 99211 in terms of key components or contributory factors. Also, unlike the other E/M codes, CMS did not provide documentation requirements for code 99211 in the “E/M Documentation Guidelines.”

Procedure code 99211 describes a service that is a face-to-face encounter with a patient consisting of elements of both evaluation and management. The evaluation portion of code 99211 is substantiated when the record includes documentation of a clinically relevant and necessary exchange of information (historical information and/or physical data) between the provider and the patient. The management portion of code 99211 is substantiated when the record demonstrates influence by the service of patient care (medical decision-making, provision of patient education, etc.). Documentation of all code 99211 services must be legible and include the identity and credentials of the individual who provided the service.

For code 99211, services performed by ancillary staff and billed by the physician as an “incident to” service, the documentation should also demonstrate the “link” between the non-physician service and the precedent physician service to which the non-physician service is incidental. Therefore, documentation of code 99211 services provided “incident to” should include the identity and credentials of both the individual who provided the service and the supervising physician. Documentation of a code 99211 service provided “incident to” should also indicate the supervising physician’s involvement with the patient care as demonstrated by one of the following:

        • Notation of the nature of involvement by the physician (the degree of which must be consistent with clinical circumstances of the care).

        • Documentation from other dates of service that establishes the link between the services of the two providers.

        • Medicare has reviewed numerous claims on which 99211 was reported inappropriately. All 99211 services for which supporting documentation does not demonstrate that an E/M service was performed and was necessary as outlined in this document will be denied upon review.

Procedure code 99211 should not be used to bill Medicare:

    • For phone calls to patients.

    • Solely for the writing of prescriptions (new or refill) when no other E/M is necessary or performed.

    • For blood pressure checks when the information obtained does not lead to management of a condition or illness.

    • When drawing blood for laboratory analysis or when performing other diagnostic tests, whether or not a claim for the venipuncture or other diagnostic study test is submitted separately.

    • Routinely when administering medications, whether or not an injection (or infusion) code is submitted on the claim separately.

    • For performing diagnostic or therapeutic procedures (especially when the procedure is otherwise usually not covered/not reimbursed or payment is bundled with payment for another service), whether or not the procedure code is submitted on the claim separately.

CPT 99211, when billed for debridement, is not routinely a skilled service, therefore, not routinely covered.

Visits for the sole purpose of routine dressing changes are noncovered.

Debridement will not be considered a reasonable and necessary procedure for a wound that is clean and free of necrotic tissue or other tissue that limits wound healing.

The routine application of a topical or local anesthetic does not elevate the service to debridement

RN and qualified ancillary staff - billable E&M services

Providers can bill 99211 for RNs or qualified ancillary staff that is employed by a physician’s office as follows:

• When the patient visit is a part of an established physician care plan requiring follow-up and is deemed medically necessary.

• RNs or qualified ancillary staff cannot code higher than a 99211 for E&M services regardless of the time spent or level of services provided.

• RNs or qualified ancillary staff cannot bill new problems or new patient visit code 99201.

• A provider and an RN or qualified ancillary staff cannot both bill for an E&M office visit within the same day. Only one E&M service per day can be billed by one provider type.


  1. The ccrn exam requirements are best for nursing field. This would be great in exams so they will be encouraged to have it.

  2. I cannot get my insurances to pay for E/M codes such as the 99213 or 99214 etc with the 25 modifier attached and the ekg code 93010. Why are they not paying this? This is for my Cardiologist. Thank you

    1. What is the denial reason? In our practice we do not add -25 to an OV with an EKG.

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