nurse visit cpt code 99211

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Find-A-Code Articles, Published 2021, September 28

When is it proper to bill nurse visits using 99211.

by   Christine Woolstenhulme, QMC QCC CMCS CPC CMRS Sep 28th, 2021 - Reviewed/Updated Aug 29th

When vaccines or injections are given in the office, coding can often get confusing; for example, is it correct to report a nurse visit using  99211  and an E/M office visit reporting  99202  ‑  99215  and include injection fees with the vaccine product? In addition, the reporting of evaluation and management (E/M) during the same visit where vaccines are administered is not always understood. The answer depends on whether the provider performs a medically necessary and significant, separately identifiable E/M visit, in addition to the immunization administration.

CMS states, when a separately identifiable E/M service (which meets a higher complexity level than CPT code  99211 ) is performed, in addition to drug administration services, you should report the appropriate E/M CPT code 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.

It is incorrect to bill a  99211  when the provider provides an E/M service that meets a higher complexity level than CPT code  99211 , you must bill the higher complexity, and you cannot bill for two services in one day. 

Charging for Nurse Visits

There are times when it is appropriate to report for a nurse visit using CPT code  99211 . The  Incident-to rule  applies when reporting this code, and services provided must be documented as medically necessary services, including the clinical history, clinical exam, making a clinical decision, and physician supervision. 

• NOTE: A nurse visit is not paid if billed with a drug administration service such as chemotherapy or non-chemotherapy drug infusion code, including therapeutic or diagnostic injection codes. The reasoning is because diagnostic IV infusion or injection services typically require direct physician supervision, and using  99211 is reported by qualified healthcare professionals other than physicians.

08/29/2023 NOTE: (These CPT codes,90782, 90783, 90784, or 90788  were deleted in 2006, but still showing in CMS - Claims processing manual) When reporting CPT codes 90782, 90783, 90784, or 90788 , CPT code 99211  cannot be reported. In addition, it is improper billing to report a visit solely for an injection that meets the definition of the injection codes. 

When the only reason for the visit is for the patient to receive an injection, payment may be made only for the injection (if it is covered). An office visit using  99211 would not be warranted where the services rendered did not constitute a regular office visit and a part of the plan of care and not at the patient's request.

Unlike other E/M codes  99202 - 99205 , and 99212 - 99215 , time alone cannot be used when reporting  99211  when selecting the appropriate code level for E/M services. Effective January 1, 2021, time was removed as an available code-selection criterion. The typical time spent on this code is five minutes.  

Other visits billed with  99211

Several other visits may be reported using  99211 , and nurses are not the only staff that can report this code; medical Assistants and technicians are also included under non-physician.  

Covid-19 Testing

According to  CMS ; Physician offices can use CPT code  99211  when office clinical staff furnish assessment of symptoms and specimen collection for Covid-19 incident to the billing professionals services for both new and established patients. When the specimen collection is performed as part of another service or procedure, such as a higher-level visit furnished by the billing practitioner, that higher-level visit code should be billed. The specimen collection would not be separately payable.

Examples from CMS

The following are examples of when  CPT  99211  might be used:

• Office visit for an established patient for blood pressure check and medication monitoring and advice. History, blood pressure recording, medications, and advice are documented, and the record establishes the necessity for the patient's visit.
• Office visit for an established patient for return to work certificate and advice (if allowed to be by other than the physician). Exam and recommendation are noted, and the Return to Work Certificate is completed, copied, and placed in the record.
• Office visit for an established patient on regular immunotherapy who developed wheezing, rash, and swollen arm after the last injection. Possible dose adjustments are discussed with the physician, and an injection is given. History, exam, dosage, and follow-up instructions are recorded.
• Office visit for an established patient's periodic methotrexate injection. Monitoring Lab tests, query signs and symptoms, obtain vital signs, repeat testing, and injection advised. All this information is recorded and reviewed by the physician. (Note that in this circumstance, if  99211  is billed, the injection code is not separately billable). An office visit for an established patient with a new or concerning bruise is checked by the nurse (whether or not the patient is taking anticoagulants), and the patient is advised on how to care for the bruise and what to be concerned about, and, if on anticoagulants, continuing or changing current dosage is advised. History, exam, dosage, and instructions are recorded and reviewed by the physician.
• Office visit for an established patient with atrial fibrillation who is taking anticoagulants and has no complaints . The patient is queried by the nurse, vital signs are obtained, the patient is observed for bruises and other problems, the prothrombin time is obtained, the physician is advised of prothrombin time and medication dose, and medication is continued at present dose with follow up prothrombin time in one month recommended. History, vital signs, exam, prothrombin time, INR, dosage, physician's decision, and follow-up instructions are recorded.

References/Resources

About christine woolstenhulme, qmc qcc cmcs cpc cmrs.

Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code.  Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.

When is it Proper to Bill Nurse Visits using 99211. (2021, September 28). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/nurse-visits-and-injections-36866.html

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Using and Documenting CPT Code 99211 Services Correctly

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Using and Documenting CPT Code 99211 Services Correctly

CPT ®  code 99211 is defined by the 2011  CPT  Standard Edition manual as:

" Office or other outpatient visit  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."

Using code 99211 to report a low-level evaluation and management (E/M) service   Code 99211 describes a face-to-face encounter with a patient consisting of elements of both evaluation (requiring documentation of a clinically relevant and necessary exchange of information)  and  management (providing patient care that influences, for example, medical decision making or patient education). Documentation must be legible and include the identity and credentials of the servicing provider.

Using code 99211 to bill an 'incident to' service   When Code 99211 is 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. Documentation should include the identity and credentials of the supervising physician and the staff that provided the service. Notes should indicate the degree of the physician’s involvement and document the link between the services of the two providers.

All 99211 services that  don’t  document or demonstrate that an E/M service was performed and necessary will be denied upon review.

Code 99211 should not be used by physician or staff to bill for:

• Administering routine medications by physician or staff whether or not an injection or infusion code is submitted separately on the claim
• Checking blood pressure when the information obtained does not lead to management of a condition or illness
• Drawing blood for laboratory analysis or for a complete blood count panel, or when performing other diagnostic tests whether or not a claim for the venipuncture or other diagnostic study test is submitted separately
• Faxing medical records
• Making telephone calls to patients to report lab results or to reschedule patient procedures
• Performing diagnostic or therapeutic procedures (especially when the procedure is otherwise usually not covered/not reimbursed, or payment is bundled with reimbursement for another service) whether or not the procedure code is submitted on the claim separately
• Recording lab results in medical records
• Reporting vaccines
• Writing prescriptions (new or refill) when no other evaluation and management is needed or performed

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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.

Related CPT Code 99211 Nurse Visits Posts:

• Coding Cast & X-ray Application During Post-op | Medical Coding Tips
• E/M with Diabetes | E&M Coding Tips
• Free Medical Coding Practice Exams – CPC Practice Exam and More!

2 thoughts on “CPT Code 99211 Nurse Visits | CPT Coding Tips”

IS CONDUCTING A BIOMETRIC WELLNESS SCREENING BY A NURSE (AS A NURSE VISIT IN AN OUTPT. CLINIC )CAN BE BILLED UNDER 99211

Unfortunately, this request is outside the scope of help we can provide on the blog. We recommend submitting it for consideration at our Topic Requests page: https://www.cco.us/topic-request/

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Appropriate Use of CPT Code 99211

Working with a diabetes educator can reduce the time physicians need to spend with each patient and increase efficiency. The term ‘incident to a physician‘s professional services means that the service was furnished as an integral, although incidental, part of the physician‘s personal professional service in the course of diagnosis or treatment of an injury or illness. Physician supervision of the diabetes educator is a key component of ‘incident to’ billing, particularly for non-certified diabetes educators.

In the physician‘s office, ‘incident to’ services must be part of the patient‘s normal course of treatment. Physicians must perform an initial service, be actively involved in the course of treatment, and record this in the patient‘s record. It is not necessary for the physician to be present in the treatment room while the services are provided by the diabetes educator, but the physician must provide direct supervision and take financial responsibility for the educator. Direct supervision means being available in the office suite.

‘Incident to’ billing may be relevant for physicians practicing in states that do not provide distinct coverage for DSMT. Physicians should check with the Medicare Carrier and/or private payor to obtain additional guidance.

The CPT® code 99211 is the only E&M code used for ‘incident to’ billing available to the physician clinic‘s ancillary staff members. Some of the other codes (in the range of 99212–99499) can, however, be billed ‘incident to’ by non-physician providers (NP, PA, CNS). Please note that Medicare regulations stipulate that neither DSMT nor MNT can be provided incident to a physician‘s services when claiming the DSMT HCPCS G codes or the MNT CPT or HCPCS G codes.

Office or other outpatient visits 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. 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.

Who can bill CPT 99211:

RNs, LPNs, Mas, CNAs, MDs, Dos, NPP, Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives

Clinical staff not eligible to bill other than CPT 99211 as the physician or NPP can perform the HPI, physical exam & MDM are considered to be the part of physician work and cannot be relegated to clinical/ancillary staff.

• The patient must be an established patient
• The visit must be a face to face encounter
• Service can be billed by physicians or NPP or by clinical staff as Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified Nursing Assistant (CNA)

Appropriate Use

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.

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 visits 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.

Examples of Office/Clinic Visits

• Diabetic counseling
• The patient recently placed on a new medication that causes weight gain. A follow-up visit is scheduled for a 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, the patient must be present in the 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

Modifier 25

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.

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Update to NCCI Edits for Allowance of 99211 With Immunization Administration

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American Academy of Pediatrics; Update to NCCI Edits for Allowance of 99211 With Immunization Administration. AAP Pediatric Coding Newsletter December 2021; 17 (3): 11. 10.1542/pcco_book212_document009

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On October 1, 2021, the Centers for Medicare & Medicaid Services (CMS) changed a procedure-to-procedure edit from modifier indicator 0 to 1. After joint work between CMS and the American Academy of Pediatrics, CMS agreed to this change to allow for reporting of code 99211 if the patient presents for a nurse-only vaccine encounter and also requires a COVID-19 test.

Modifier 25 is required with 99211 , which means there must be documentation to support code 99211 as a separate service and it may never be used for a vaccine-only visit. CMS will revisit this decision at the end of the public health emergency. For more information, visit https://downloads.aap.org/AAP/PDF/AAP%20Position%20Paper%20EM%20IA.pdf .

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How to Code for Telehealth, Audio-Only, and Virtual-Digital Visits 

Learn how to accurately get paid for telemedicine services with medical codes for telehealth, audio-only, and virtual-digital visits.

Looking for additional telemedicine coding resources?

Coding for Telehealth Visits

Note:  These tables are informational, not advisory. The AAFP recommends that physicians verify each payer's policy and ask patients to verify their coverage ahead of appointments. 

How do I code a new or established patient telehealth office visit that uses audio-video communications technology?

* Elevance's  policies vary by state; contact your provider-relations representative.

Coding for Audio-only Visits

How do i code an audio-only visit for a new or established patient .

CPT Codes: 99441-99443 

Audio-only scenario notes 

Medicare requires audio-video for most office visit evaluation and management (E/M) services (CPT codes 99202-99215) telehealth services. Audio-only encounters are allowed for certain services. Eligible services may be found on the Medicare Telehealth Services list. Medicare allows audio-only telehealth services for office visit E/M services (CPT codes 99202-99215) for the treatment of mental health conditions.   

UHC states they will consider payment for eligible audio-only services listed in Appendix P of the CPT book. Eligible services must be reported using either POS 02 or 10 and include the -93 modifier. CPT codes billed with modifier -93 that are not in Appendix P will not be considered for payment.   

Private payers vary on covered telehealth services. Check with your provider relations representatives for each payer’s telehealth policy and covered telehealth services. 

CMS will cover telephone evaluation and management (E/M) services (CPT codes 99441-99443) through the end of calendar year 2023. Other services that may be provided via audio-only are available on the Medicare Telehealth List. 

Telephone E/M services are provided to a patient, parent, or guardian and do not originate from a related E/M service within the previous seven days and do not lead to an E/M service or procedure within the next 24 hours or soonest available appointment. 

The following codes may be used by physicians or other qualified health professionals who may report E/M services: 

• 99441: telephone E/M service; 5-10 minutes of medical discussion 
• 99442: telephone E/M service; 11-20 minutes of medical discussion 
• 99443: telephone E/M service, 21-30 minutes of medical discussion 

Telephone E/M services should not be reported when the time spent on the telephone is captured in other services reported, such as: 

• if CPT codes 99421-99423 have been reported by the same physician in the previous seven days for the same problem, 
• when CPT codes 99339-99340 and 99374-99380 are used for the same call, 
• during the same month with CPT codes 99487 and 99489, and 
• when performed during the same service period at CPT codes 99495-99496. 
• Self-funded plans can develop their own policies and may opt out of some cost-sharing waivers. Similarly, Medicaid policies are established at the state-level. The AAFP recommends reaching out to your provider relations representatives or Medicare Administrative Contractors (MACs) to verify policies.  

Coding for Virtual-Digital Visits 

How do i code an e-visit (cpt 99421-99423) for an established patient .

CPT Codes: 99421-99423 

How do I code a virtual check-in (HCPCS codes G2012 and G2010) for an established patient? 

HCPCS Codes: G2012, G2252, G2010 

Virtual/Digital Scenario Notes 

• Patient consent is required and may be obtained either before or at the time of service. 
• Virtual check-ins and e-visits must technically be initiated by a patient; however, physicians and other providers may need to educate beneficiaries on the availability of the service prior to patient initiation. 
• There are no POS or modifier requirements for virtual check-ins or e-visits. Use the POS used for typical services. 

Virtual Check-in (HCPCS Code G2012, G2252) 

• These are brief conversations with a physician or other clinician to determine if an in-person visit is necessary. 
• The communication cannot be related to a medical visit within the previous seven days and cannot lead to medical visit within the next 24 hours (or soonest appointment available). 
• Physician or other clinician may respond to patient by telephone, audio/video, secure text messaging, email, or patient portal. 
• HCPCS code G2010 can be used when a captured video or image (store and forward) is sent to the physician. The physician must follow up with the patient within 24 business hours. The consultation must not originate from an evaluation and management (E/M) service provided within the previous seven days or lead to an E/M service within the next 24 hours (or soonest available appointment). 

E-Visits (online digital evaluation and management services) 

• These are non-face-to-face, patient-initiated communications with the physician through an online patient portal. The communications can occur over a seven-day period, and the exchange must be stored permanently. 
• Cumulative time includes review of the initial inquiry, review of patient records pertinent to the assessment of the patient’s problem, personal interaction with clinical staff focused on the patient’s problem, development of management plans (including generation of prescriptions or ordering of tests), and subsequent communication with the patient. Communication can occur through online, telephone, email, or other digitally supported communication 

Physicians and other clinicians who may independently bill Medicare for E/M services can use the following codes:

• 99421: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes 
• 99422: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes 
• 99423: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes 

E-visits should not be billed on the same day the physician reports an office visit E/M service (CPT codes 99202-99205 and 99211-99215) for the same patient. Additionally, e-visits should not be billed when using the following codes for the same communication: 

• 99339-99340 
• 99374-99380 
• 99487 and 99489 
• 99495-99466 

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