Monday, November 28, 2011

CPT cod 99211 - when to bill and not getting paid - required documentaiton

Documentation Requirements for 99211

CPT code 99211 is a code used to report a low-level E/M service. Code 99211 requires a face-to-face patient encounter but when billed as an “incident to” service, it may be performed by ancillary staff and billed as if the physician personally performed the service.

The CPT 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 billed to Medicare must be reasonable and necessary for the diagnosis or treatment of an illness or injury. Unlike the other E/M CPT codes, CPT 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.

CPT 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 whose 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

Among other things, 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 a claim for the venipuncture or other diagnostic study test is submitted separately.
* Routinely when administering medications whether 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.

No comments:

Post a Comment

Most read cpt modifiers