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April 12, 2002

Coding Consult: Low-level codes can bring in high revenue

Coding Consult
Low-level codes can bring in high revenue
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So-called "nursing codes" can be income generators if you use them correctly.

Proper use of low-level office visit codes (99201 and 99211) can provide an important revenue stream.
However, many practices misuse these codes, losing out on income and risking trouble during an audit.

Established patient code 99211 is often referred to as a "nurse visit." This basic level of service doesn't require
the presence of a physician, nurse practitioner, or physician assistant. It's usually provided by an RN, LPN, or
certified medical assistant.

Linda Jackson, Medicare consultant at Iowa Veterans Home, a residential facility that provides professionally
managed health care for aging veterans in Marshall Town, IA, cites the following examples of when 99211 may
be assigned:

• Suture removal.
• Simple ear lavage.
• Blood pressure checks.
• Patient teaching for diabetics.

Unlike other office visit E&M codes, 99211 requires no documentation for history, physical exam, or medical
decision-making. But certain criteria must be met. "The nurse must meet with the patient and document the
date, reason for the patient's visit, findings of the visit, and the service provided per the doctor's order,"
Jackson explains. "And the nurse must sign the note."

Most 99211 visits are billed as "incident to" services and must follow the appropriate guidelines. "First, the
physician or midlevel practitioner must have originally established a treatment plan," Jackson says. Second,
the physician or midlevel must directly supervise the nurse. Although they need not be in the exam room, they
must be physically present in the office or clinic. "Availability by phone does not meet the requirement,"
Jackson adds.

This low-level code isn't always billed as "incident to." You can also claim a 99211, for example, when an
established patient comes in for a nurse's signature on a return-to-work certificate.

When not to report 99211

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Jackson stresses the importance of educating coders on 99211 guidelines. Examples of mistaken application of
99211 include:

• Telephone calls to discuss prescription refills, test results, or diagnoses, or to explain specific aspects of care.
These should be billed with 99371-73 (case management services, telephone calls).
• Time spent reviewing records and tests when the patient isn't present, arranging for further services, or
communicating with other professionals through written reports or telephone contacts.
• Completion of forms like home health or durable-equipment certifications.
• Delivery by the patient of a lab specimen at the office for a follow-up on a previous complaint or diagnosis
when no other service is provided at that time.
• Services to homebound patients.

Jackson also points out that 99211 should not be reported when a patient is seen in the office simply for an
injection or blood draw. The services provided by the nurse or medical technician are included in the
procedure charge.

Some practices choose not to assign 99211 even when it is appropriate—such as for a TB skin test—as a public-
relations gesture to patients. "Many practices—especially those in low-income and rural areas—want to be 'nice
guys' to their patients," Jackson says. "But practices need to charge for services they provide."

Sometimes an appointment that began as a nurse visit escalates. Perhaps the patient's blood pressure is
significantly elevated or the nurse observes a possible infection when changing a dressing. Instances like these
demand a physician's attention and will probably include a physical exam, history, and increased medical
decision-making.

Tammy Chidester, billing supervisor at Upshur Medical Management Services, a multispecialty group in
Buckhannon, WV, says these components justify a higher-level E&M code—perhaps a 99212 or 99213.
"Because the initial visit turns into a doctor's visit, coders cannot bill for the nurse visit (99211). Instead, coders
should report only the physician's service with a higher-level E&M code," she says.

99201 used in limited situations

Although not reported as often, 99201 is used for limited new patient encounters. Because the patient has not
been seen before, the physician or midlevel must provide the care and document a problem-focused history,
problem-focused exam, and straightforward medical decision-making.

Chidester cites a typical example of 99201's application: A person is away from home and needs a prescription
refill. A physician conducts a limited exam and refills the prescription. "Another example is a new patient who
comes in for an initial office visit with sunburn that requires first aid. The visit is focused, and the doctor treats
the specific issue," she explains.

Obviously, such situations are rare because even if no major problem prompted the visit, the physician will
probably conduct a thorough exam and history—which would represent a higher-level E&M service. But still,
when they do occur, you might as well get paid for them.

This information provided by The Coding Institute. For a free sample issue or information on how to
subscribe to any of 29 specialty-specific coding newsletters, please contact The Coding Institute, 2272
Airport Rd. South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592; or visit
www.codinginstitute.com .

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