99211 nurse visit guidelines 2023

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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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2022 Coding Update for CPT 99211

While code descriptors are never big news, one key change to a low-level office/outpatient (E/M) service code descriptor that came into effect on January 1, 2022, could be a welcome change for your practice. The revision is the level one office/outpatient E/M code for established patients.  In 2022, the CPT 99211 descriptor reads as, 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 healthcare professional.

While the 2021 descriptor was, 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.

The phrase ‘Usually, the presenting problem(s) are minimal’ has been deleted to bring the descriptor for CPT 99211 more in line with the rest of the office/outpatient evaluation and management (E/M) codes. With the phrase removal, 99211’s descriptor is now more synched with the other office/outpatient E/Ms: 99202 through 99215.

This change eliminates a source of confusion as to what is a minimal problem and what is not. Even with the change, CPT 99211 still represents an E/M service provided by clinical staff as opposed to a physician or other qualified healthcare professional who may report higher levels of E/M services.

Services described by 99211 must be medically necessary (i.e., clinically indicated) and be part of a plan of care by a physician or other qualified healthcare professional. This is why 99211 is not reportable for providing a service at a patient’s request rather than as part of an established plan of care.

Basic Guidelines for CPT 99211

The following guidelines can help you decide whether a service qualifies for 99211:

• The patient must be established. CPT 99211 cannot be reported for services provided to patients who are new to the physician.
• An E/M service must be provided. Generally, this means that the patient’s history is reviewed, a limited physical assessment is performed or some degree of decision-making occurs. 99211 would not be appropriate when a patient comes into the office just to pick up a routine prescription.
• Keep in mind that if another CPT code more accurately describes the service being provided, that code should be reported instead of 99211. For example, if a physician instructs a patient to come to the office to have blood drawn for routine labs, the nurse or lab technician should report CPT code 36415 (routine venipuncture) instead of 99211 since an E/M service was not required.
• The service must be separate from other services performed on the same day. For example, if a nurse provides instructions following a physician’s minor procedure or takes a patient’s vital signs prior to an encounter with the physician, 99211 should not be reported for these activities because they are considered part of the E/M service already being provided by the physician.
• The presence of a physician is not always required. Although physicians can report 99211, CPT’s intent with the code is to provide a mechanism to report services rendered by other individuals in the practice (such as a nurse or other clinical staff member). According to CPT, the staff member may communicate with the physician, but direct intervention by the physician is not required.
• Medicare’s requirements on this point are slightly different: While the physician’s presence is not required at every 99211 services involving a Medicare patient, the physician must have initiated the service as part of a continuing plan of care in which he or she will be an ongoing participant. For some insurance carriers, this means that the physician must see the patient at least every third visit. In addition, the physician must at least be in the office suite when each service is provided. 
• No key components are required. Unlike other office visit E/M codes, such as 99212, which require at least two of three key components (problem-focused history, problem-focused examination, and straightforward medical decision making), the documentation of a 99211 visit does not have any specific key-component requirements. Rather, the note just needs to include sufficient information to support the reason for the encounter and E/M service and any relevant history, physical assessment, and plan of care. The date of service and the identity of the person providing the care should be noted along with any interaction with the supervising physician. 

Improve Collections with CPT

Reporting CPT 99211 can bring additional revenue into your practice. Specific payment amounts will vary by payer, but the average unadjusted 2021 payment from Medicare for a 99211 service was $23.03. This means that only five 99211 encounters with Medicare patients in a week will result in over $5,000 per year for practice.

Although this may not sound like a lot of money, it is easy revenue. Most practices already provide a number of 99211 services but fail to capture those charges. Remember, all services have a cost associated with them, and practices need to recoup as much of these costs as is legitimately possible.

As mentioned above, physicians can report 99211, but it is intended to report services rendered by other individuals in the practice, such as a nurses or other staff members. Appropriately reporting 99211 services can also improve documentation in a practice.

Staff members who are cognizant of billing guidelines tend to pay increased attention to documentation, which, in turn, can result in a more useful medical record for all providers involved in the care of the patient.

About Medical Billers and Coders (MBC)

Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle solutions.  We keep on sharing billing and coding updates as per various medical specialties. We hope you have received updated information to use CPT 99211 accurately.

If you need any help in medical billing and coding for your practice, email us at: [email protected] or call us at: 888-357-3226 .

1. What is CPT code 99211 used for?

CPT code 99211 is for office or outpatient visits for established patients where a physician or qualified professional’s presence is not required.

2. What change was made to CPT code 99211 in 2022?

The phrase “Usually, the presenting problem(s) are minimal” was removed to align the code with other office/outpatient E/M codes.

3. What are the basic guidelines for using CPT code 99211?

CPT 99211 is used for established patients needing E/M services by clinical staff, not for routine services like prescription pickups.

4. Is the presence of a physician required when using CPT code 99211?

The physician’s direct presence is not required, but the service should be part of a continuing care plan initiated by the physician.

5. How can reporting CPT code 99211 benefit a practice?

Accurate reporting of CPT 99211 can increase revenue, with potential additional earnings from Medicare, and improve overall documentation practices.

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• October 2022 | Volume 107...
• For Your Practice

What Surgeons Should Know

2023 changes to reporting inpatient and observation evaluation and management services.

Jan Nagle, MS, and Teri Romano, BSN, MBA, CPC, CMDP

October 1, 2022

In 2021, the Current Procedural Terminology (CPT*) Editorial Panel revised the office/outpatient evaluation and management (E/M) codes (99202–99205, 99211–99215). For CPT 2023, the panel has revised additional families of E/M codes to be consistent with the changes to the office/outpatient E/M codes. This column focuses on the changes to the hospital inpatient and hospital observation E/M codes that surgeons routinely use. 

Will there continue to be separate E/M codes for inpatient and observation care in 2023?

No, for 2023, the codes for reporting observation care services (99217–99220) will be deleted and observation care services will be merged into the codes previously used to report only inpatient care services (99221–99233, 99238–99239). See Table 1 for the revised 2023 code descriptors. Although the same code will be used to report either inpatient or observation care services, you will still need to know the facility status of the patient to accurately report the place of service code as either hospital inpatient (21) or hospital outpatient (22).

Will there continue to be separate codes for initial and subsequent hospital visits?

Yes, codes 99221–99223 will continue to be reported for new patients and codes 99231–99233 will continue to be reported for established patients.

In addition to merging inpatient and observation care services into single codes, how else has this family of codes changed?

Similar to the changes made to the office/outpatient E/M codes, only a “medically appropriate” history and/or examination will be required for reporting inpatient/observation care services. The extent of history and physical examination is not an element in selecting the level of these E/M codes. In addition, references to a “focused, detailed, or comprehensive” history and/or examination have been removed from the code descriptors.

How do I select the correct code?

Code selection will be based on either the level of medical decision-making (MDM) as defined for each service or the total time on the date of the encounter. These elements will be used for selecting all hospital E/M visit codes with the exception of emergency department visit codes (which only use MDM) and critical care services codes (which only use time). 

How is MDM used to select the level of code?

For codes 99221–99223 and 99231–99233, the level (straightforward, low, moderate, high) of MDM selected is based on two of the three elements of MDM: (1) number and complexity of problems addressed at the encounter, (2) amount and/or complexity of data to be reviewed and analyzed, and/or (3) risk of complications and/or morbidity or mortality of patient management. These are exactly the same elements used to select a level of office/outpatient E/M services code.

How do I use total time to select a level of code?

When time is used for reporting inpatient/observation care E/M services codes, the time defined in the code descriptors is used for selecting the appropriate level of services. The time includes both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician and/or other qualified healthcare professional (QHP) on the date of the encounter. It includes time regardless of the location of the physician/QHP (for example, whether on or off the inpatient/observation unit). It does not include any time spent in the performance of other separately reported procedures or service(s). For coding purposes, time for these services is the total time on the date of the encounter.

How is time reported if both the physician and QHP provide face-to-face and non-face-to-face services on the day of encounter?

A visit in which a physician and QHP both provide services related to the visit is defined as a split or shared visit. When time is being used to select the appropriate level of services for which time-based reporting of split/shared visits is allowed, the time personally spent by the physician and QHP assessing and managing the patient and/or counseling, educating, communicating results to the patient/family/caregiver on the date of the encounter is summed to define total time. However, remember that only distinct time should be summed for split/shared visits (for example, when two or more individuals jointly meet with or discuss the patient, only the time of one individual should be counted).

I have heard there are new restrictions for reporting split/shared visits—is this true?

For Medicare patients in 2022, the Centers for Medicare & Medicaid Services finalized that the treating provider who performs the “substantive portion” of the visit will bill the service. For more information on 2022 reporting, see the April 2022 issue of the Bulletin. For 2023, based on negative comments about the plan that CMS created for 2022, along with changes to the code descriptors, the reporting requirements for a split/shared visit are under review. Look for an update after the final rule for the 2023 physician fee schedule is released in November.

What resources does the ACS offer to improve my coding skills?

The ACS collaborates with KarenZupko & Associates (KZA) to offer coding courses that provide the tools necessary to increase revenue and decrease compliance risk. These courses are an opportunity to sharpen your coding skills. You also will be provided online access to the KZA alumni site, where you will find additional resources and frequently asked questions about correct coding. Additional information about the courses and registration can be accessed at karenzupko.com/general-surgery .

* All specific references to CPT codes and descriptions are © 2022 American Medical Association. All rights reserved. CPT is a registered trademark of the AMA.

Jan Nagle is an independent consultant in Chicago, IL, who assists with AMA CPT coding education and health data analyses.

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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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Changes in CPT language for 99211

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Has the CPT language for 99211 changed over the past few years? Yes. Previously, from 1997 to 2020, CPT description said: 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 spent performing or supervising these services. During the public health emergency, Medicare allowed these exemptions: 99211 could be reported “via telemedicine with virtual physician supervision and signature for new and established patients.” For 2021, the CPT description says: 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 problems(s) are minimal. The time component was removed. It’s changing again beginning Jan. 1, 2022: 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. Level of presenting problem has been removed. What else you need to know: The “technician code” in 2022 may be reported for telemedicine as indicated by the star in front of the code. To submit 99211, a physician’s documented order must detail what elements of the exam are medically necessary to perform. This can’t be a standing order, but unique to the needs of the patient. The ordering or supervising physician must be onsite in the office suite. The physician must be onsite in the office suite. The physician must sign off on the chart note because the exam is billed under his or her NPI. All testing services are bundled with 99211 when performed the same day.

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Public & Patients

If you're forgetting to bill 99211 for nursing visits, or using 99201 when you should be using 99202, this quick coding lesson may improve your practice's bottom line .

JAMES M. GIOVINO, MD

Fam Pract Manag. 2000;7(7):39-42

Level-one” office visits may be the simplest of patient encounters, but when it comes to coding and documentation, they are widely misunderstood. More often than not, we tend to forget to bill 99211 for nursing visits and we undercode physician visits. One of the key problems, of course, is that the rules for coding and documentation are clear as mud, while the threat of audit is clear as day. The revised revised documentation guidelines, which are at least a year away from being implemented, may help the situation. But until then, family physicians can do better by reacquainting themselves with the most effective use of level-one evaluation and management (E/M) office visit codes.

According to the CPT manual, a 99211 is an office or other outpatient visit “that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services.” Unlike the rest of the office visit codes, 99211 does not have any documentation requirements for the history, physical exam or complexity of medical decision making. The nature of the presenting problem need be only “minimal,” such as monthly B-12 injections, suture removal, dressing changes, allergy injections with observation by a nurse, and peak flow meter instruction. (For more examples, see Appendix D of the CPT manual.)

KEY POINTS:

Physicians generally should not use a 99211 code for their own services, but it may be appropriate for office services performed by a nurse.

To support the 99211 code for a nursing visit, a practice must have sufficient documentation.

If physicians use code 99201 regularly, they are likely undervaluing or under-documenting their services.

None of these visits requires the presence of a physician in the exam room (although the physician should be on the premises). In fact, as a rule of thumb, a physician should not code a 99211. What these visits do require is supporting documentation, so if you plan to charge for nurses' visits, you need to train your nurses to provide very basic medical documentation. I have found the most successful method for achieving adequate and consistent documentation from nurses is to make simple, check-box-driven forms, which guide nurses' decision making, protect you from litigation and give you the clinical data you would want yourself. (For examples of flow sheets that can assist nurses in documentation, see " Documenation help .")

Documentation help

Nurse charting for 99211 visits can be minimized and made more efficient by moving it almost entirely to flow sheets, such as the two available for download below. Longer notes, such as involved phone messages, can be documented in the progress note section of the chart to avoid filling up the flow sheet with narrative information. Nursing data need not be repeated in the progress note.

In the flow sheet for depo-progesterone injections (

), the idea is, first, to collect the data needed to protect the patient from iatrogenic injury; second, to drive effective billing; and third, to minimize the effort needed for adequate documentation.

The vital signs flow sheet (

) not only improves nurses' documentation but improves physician efficiency as well by allowing for rapid review of vital signs, past office visits, routine health care and medications. To inform the physician of a chief complaint, the nurse can simply attach a sticky note to the front of the chart. Scan the sample vital signs flow sheet and see if you can get a feel for this patient without reading the progress notes.

Note that, in our practice, we highlight no-show appointments and narcotic/benzodiazepine prescriptions in green and yellow, respectively. We have found that these features alone make the form worthwhile.

If you are not sure it is worth the effort to bill for a 99211, consider that a nursing visit for a depo-progesterone shot can generate a charge of approximately $150 (nursing visit 99211=$30, Depo-Provera 150 mg J1055=$90, urine pregnancy test 81025=$38), which even after insurer discounts is a significant amount. In my office, before we standardized nursing documentation and billing, we failed to capture approximately $4,000 per year for various portions of the nursing visit for depo-progesterone shots alone. The cost to standardize nursing documentation is minimal: a few copies of a form per year. The nurses spend no more time charting and are less confused about what they should be doing.

One word of caution about 99211: You can't bill for the administration of an injectable medication (90782) or for the administration of an immunization (90471, 90472) and a nursing visit at the same time. You can either bill for the 99211 plus the medications or bill for the injection plus the medications. When the nurse must make an evaluation of the patient (e.g., when giving a depo-progesterone shot, the nurse must consider, “might the patient be pregnant?”), then our practice uses the 99211. If the nurse must only give an injection, we use the injection codes.

In general, of the “new patient” codes, 99201 should be used only slightly less frequently than 99205. The goal is not to game the system and upcode, but if you find yourself using 99201 regularly, consider auditing your own billing and documentation practices. You will most likely find that you are either undervaluing your services or underdocumenting.

The 99201 code has more specific requirements than 99211 when it comes to elements of the history, physical and medical decision making. (See the table below, for the minimum required elements .) In addition, 99201 is not to be used for nursing visits, as the physician needs to see the patient and establish a care plan before nurses' visits can be billed.

Examples of typical 99201-type office visits from the CPT manual include an out-of-town patient needing refills on an NSAID, a topical preparation or an antihistamine for allergies. For documentation, remember to record a chief complaint, one element from the HPI and one physical exam bullet, and specify a diagnosis and plan.

99201 quick reference

Unlike code 99211, which has no specific documentation requirements, code 99201 for the evaluation and management of a new patient requires a problem-focused history, a problem-focused examination and straightforward decision making, as outlined in the table at right.

Bottom line

When it comes to level-one office visits, three general rules should keep you on track:

Don't forget to bill for the nurse's time and expertise by using the 99211 code.

Use check-box forms to drive adequate documentation, to achieve consistency between nurses and to capture all appropriate fees.

Consider the use of a 99211 or 99201 for a physician visit as a red flag indicating potential undercoding.

If you are tempted to downcode for your poorer patients, remember that you will be committing fraud by billing one group of patients differently from another. Medicare gets very upset about this. The best way to help your patients who are less able to pay is to use the correct billing codes and documentation but use financial hardship forms to adjust their bills or set up reasonable payment schedules.

Proper coding and documentation is crucial to the success of any medical practice. If you spend a little time making sure you and your staff understand level-one visits, you may find that it enhances your practice's bottom line and protects you from legal trouble.

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