The Proper Use of Evaluation and Management CPT Code 99211

When properly used and reported, evaluation and management service code 99211 can be useful, time saving and profitable.

The description for code 99211 reads, “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.”

 Let's Review:

 The patient must be an established patient for 99211 to be used.

1. Although a qualified medical provider or physician CAN be present, it is NOT REQUIRED.  This means that a nurse or medical assistant can report this code when the services provided meet the specified criteria.
2. Problems must be minor (suture removal, wound check, blood pressure readings, strep results, medication reviews, etc.) meaning that the problem falls under the authorized duties of a nurse or medical assistant.
3. The service will take approximately 5 minutes to perform.
4. Documentation must show the criteria has been met to charge for the visit.

 Example of 99211 Properly Reported:

Pain management practices often require patients taking high-risk medications to undergo pill counts and random urine drug screens.  These patients are followed closely to ensure they are taking their medications as prescribed, not selling them or giving them away or abusing them in any way.

If a patient is asked to return for a visit with the medical assistant, to undergo a urine drug screen,reporting 99211 for the work the medical assistant does in obtaining and testing the urine is not appropriate.  There is a CPT code for urine collection and testing and the provider can obtain and review the results at his convenience.

If, however, the medical assistant has been charged with the performance of specific tasks and inquiries of the patient and to report them to the provider so a decision can be made, then CPT 99211 may be appropriate. 

For example, a medical assistant is charged with the duty to:

1.  Perform a pill count in the presence of the patient, to determine if the patient is compliant on his

    medication regimen

2.  Perform a urine drug screen to verify no other drugs are found in his/her system

3.  Review the efficacy of the medications with the patient and note the patient’s responses.

4.  Review the findings with the provider without patient-provider interaction.

5.  Review with the patient the provider’s decision making (maybe refilling the patient’s 

    medication or denying a refill based on the findings).

6.  Documenting the visit in the patient’s medical record.

The catch here, is to remember that if the service being performed has an assigned CPT code that explains the work required for that service, and nothing else is done then it would be inappropriate to report 99211.  

 Examples of inappropriate uses of 99211:

1. Patient returns for weekly INR only.  No counseling face-to-face is performed and the provider does not make any changes to the medications.
2. Patient returns for suture removal, for surgery done by this provider, during the postoperative period and the suture removal is straightforward and requires no medical decision making or consultation with the doctor.
3. Blood pressure readings are done without any decision-making being performed.
4. Administration of a vaccine (there are specific codes to report these and the medical assistant’s administration of the vaccine).
5. Drug administration codes (again, injecting the drug, which is done by the nurse or medical assistant is covered in the codes selected to report the vaccination/administration of it).
6. Phlebotomy services (specimen collection services).

 What Should Be Documented for 99211?

The medical assistant or nurse that is attending the patient should document the service in the patient’s medical record.  This is an evaluation and management service, so documentation of a history, vital signs, test results and any medical decision making should be documented.

 Important Notice:

Some insurance companies will request the notes associated with the service performed before they will make a determination as to whether or not they will pay for it.  This is done because historically, 99211 has been inappropriately billed and there has been a serious lack of documentation to qualify it for the service.

 If you can show the medical necessity of the service through proper documentation the likelihood of being paid when reporting 99211 is much greater.

 Medical assistants who can help to ease the provider-patient load can very helpful.  Review the services medical assistants and/or nurses can provide to ease the provider-patient load.  Organize schedules and provide a room for the services to take place.  Set up the documentation template or review how to start a note and sign it when done with it with them so that proper documentation can take place.   Then get started.

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