Reporting Low-Level 99211, you Still Need Complete Documentation

Just because 99211 is known as a 'nurse visit' does not mean you can code it minus the proper notes.

When your practitioner carries out a level-one established patient evaluation & management (E/M service) , most likely you go for 99211 without much thought since the so-called 'nurse's code' only shells out about $19.00. But then you should put just as much effort into ensuring that you are reporting 99211 as correctly as your other codes. Not only is it compliant and correct coding to do so, but Medicare Administrative Contractors (MACs) are keeping a close watch.

Some time back, WPS Medicare, a Part B payer in Illinois, Michigan, Minnesota, and Wisconsin, updated the results of its Comprehensive Error Rate Testing (CERT) review, noting that it found many errors among the claims for 99211--most of which related to a lack of thorough documentation.

For example, the Comprehensive Error Rate Testing (CERT) reviewer said that a chart only included documentation of a prothrombin anticoagulation check, with no notes about an evaluation and management visit; but then the practice billed both 85610 (Prothrombin time) and 99211. One more chart specifically stated, "Patient had only labs done. Did not see the doctor," but then still billed 99211.

Even visits where the doctor is confirmed to have seen the patient were under-documented, WPS Medicare found out. For example, one record said that the patient presented 'for his first Synvisc injection" and the provider billed the arthrocentesis and Synvisc injection codes along with 99211 and modifier 25. But then submitted documentation does not support modifier code," the reviewer noted. "Documentation states, 'Detailed note is in the chart from his last visit.'"

You must document face to face visit

As with the other evaluation & management (E/M) codes in the 99201-99215 category range, your 99211 claims "must be reasonable and necessary for the diagnosis and treatment of an illness or injury," WPS Medicare reminds practices." "Furthermore, a face to face encounter with a patient comprising elements of both evaluation & management is called for."

You should not go for 99211 if the provider simply calls a patient on the phone, draws blood or administers medications when an injection or infusion code is separately submitted, according to WPS.

For more on WPS Medicare's audit of 99211 claims and the Medicare Administrative Contractor's (MAC's) tips on reporting, stay tuned to a one-stop medical coding guide like Supercoder.