Friday, July 22, 2016

when should not use CPT code 99211 Medicare

CPT 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.

The table below contains elements that would constitute adequate documentation of a code 99211 service in selected clinical circumstances:


Clinical Circumstance
Adequate Documentation for Code 99211
Blood pressure check
1. Blood pressure and other vital signs recorded.
2. Clinical reason for checking blood pressure recorded (i.e., follow up to previous abnormal finding, symptoms suggestive of abnormal blood pressure, etc).
3. Current medications listed (with notation of level of compliance).
4. Indication of doctor’s evaluation of the clinical information obtained and his management recommendation.
5. Identity and credentials of provider(s) as listed in text above.

ClinicalAdequate Documentation for Code 99211 Circumstan ce
Prescription refill or injection/infusion
1. Reason for the visit. A physician visit is not necessary to routinely provide stable patients with an ongoing medication supply. Therefore, the documentation for code 99211 or any other E/M code in this circumstance must demonstrate a need for clinical evaluation and management (for instance, symptoms or signs reported that are significant enough to necessitate evaluation).
2. Current medications listed (with notation of level of compliance).
3. Indication of doctor’s evaluation of the clinical information obtained and his management recommendation.
4. Identity and credentials of provider(s) as listed in text above.
Prothrombin time evaluation for patients on chronic warfarin anticoagulation
1. Reason for the visit. A physician visit is not routinely necessary to draw blood for prothrombin time or other laboratory tests. Therefore, the documentation for code 99211 or any other E/M code in this circumstance must demonstrate a need for clinical evaluation and management. In this case, services that would serve to demonstrate that evaluation and management was performed include an evaluation of significant new symptoms (such as excessive bruising or hemorrhage). Alternatively, for patients who have no new clinical concerns, documentation that contemporaneous laboratory values were obtained, reviewed, and used to guide current and/or future therapy documents that a separately payable E/M service has been performed.
2. Current medications listed (with notation of level of compliance).
3. Indication of doctor’s evaluation of the information about signs/symptoms and laboratory test result and his management recommendation.
4. Identity and credentials of provider(s) as listed in text above.

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