CPT Code 99211 Nurse Visits | CPT Coding Tips

Q: “Can someone please discuss CPT Code 99211?

A: Why, sure, we can. Unlike Alicia, I wanted Chandra to do my answer sheet because I always have best intentions but normally the Thursday of the webinar we’re all running around and I’m like, “Last minute Laureen,” and it’s a very bad habit. At any rate, answer prepared by Chandra, presented by Laureen but it’s a real quickie so we’ll get right to your chat questions.

First of all, what’s the definition of 99211? We’ve got our new patient codes and we’ve got our established patient codes for evaluation and management. The 99211 is the first code for established outpatient but it’s very unique. It doesn’t have the common three bullets – history, exam and medical decision making – like you see with the other codes and it’s often referred to as the nurse visit code.

VIDEO: CPT Code 99211 Nurse Visits | CPT Coding Tips

Here’s the definition: 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 healthcare professional. Usually the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services. So, the not requiring a physician is why they call it a nurse visit code.

Generally, it’s often ancillary nursing staff that’s going to be providing the services during the encounters and it is an E/M service, so there is some HEM going on – history, exam, medical decision making. But CPT doesn’t specify which areas or the amount like they do with other codes where they have discrete levels of history, exam and medical decision making.

Medicare places further restrictions on reporting 99211 by lumping it into the types of services typically performed “incident to” the physician’s services. What that means is under the “incident to” practice the physician must have established the plan. So, it’s not the nurses just taking over and treating the patient. The physician has established the plan and the nurses during follow-up in relation to that. So, that’s what that “incident to” is talking about and there has to be direct supervision. It means the physician has to be immediately available in the office suite to take over care should the need arise.

There must be a documented need for the services provided and the ancillary staff may not address any new problems or change any portion of the plan of care and order for the service to be considered “incident to.” The physician must also periodically see the patient – that would be nice. Some insurance carriers further specify this by defining “periodically” as at least every third visit.

So, if a patient is coming in for a routine thing that the doctor is aware of, he has established the plan, he’d say, “OK, poke your head in every third visit just to make sure everything’s going well.”

The types of services typically provided during these encounters are evaluation and management services considered minor in nature that do not meet any other code definition, such as blood pressure checks, weight checks, etc.

Some providers feel it is appropriate to report a nurse visit (99211) in addition to venipunctures, immunizations, etc. However, most insurance carriers will deny these… they will bundle them together. The reason is, for immunizations, the provider is already receiving payment for the E/M portion of the service… or, in the case of the venipuncture, the bundle the minimal E/M service provided into the payment for the venipuncture… They don’t want you to double dip.

For more information on CPT® code 99211 and nurse visits, here are a few articles and references that may be helpful. Again, advantage of being in the Replay Club, you get all these links and benefits of our research. That was my quickie question on nurse visits and thank you Chandra for doing that nice answer sheet for us.

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