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The requirements for most evaluation and management (E/M) codes have gotten more precise over the years. However, one notable exception to this is CPT’s level-I established patient encounter code, 99211. CPT defines this code as an “office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician.” It further states that the presenting problems are usually minimal, and typically five minutes are spent performing or supervising these services. Yet many physicians still struggle with when – or why – to report this code. This article describes how appropriately reporting 99211 can improve revenue and documentation, and provides specific guidelines and examples that can help physicians identify appropriate uses for the code. The benefits of 99211Reporting 99211 can bring additional revenue into your practice. Specific payment amounts will vary by payer, but the average unadjusted 2004 payment from Medicare for a 99211 service is $21. This means that only five 99211 encounters with Medicare patients in a week will result in over $5,000 per year for a 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. 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. KEY POINTS
Basic guidelinesThe following guidelines can help you decide whether a service qualifies for 99211:
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.
Examples of 99211 servicesCode 99211 is commonly used for services such as patient education, simple rechecks and medication reviews. Some procedures can also appropriately be reported with this code. To gain a better sense of the kinds of services that would qualify as a 99211, consult appendix C of the CPT manual and consider the following examples:
Use good judgmentBecause some services are more appropriately reported with a CPT code other than 99211, because not every encounter has a clinical indication that supports a separate visit code and because some patients may balk at the idea of being charged for some 99211 services (such as a blood-pressure check) be cautious about establishing a practice of billing an E/M service with every staff encounter. Instead, use these guidelines and examples to determine the appropriate uses of 99211. Many Medicare carriers and other third-party payers periodically issue examples and guidelines regarding the proper use of certain codes, including this one. Staying knowledgeable about these coding practices can improve your practice’s reimbursement and reduce potential audit liability. When an unlisted procedure or service code is reported?When an unlisted procedure or service code is reported, this "report" must accompany the claim to describe the nature, extent, and need for the procedure or service along with the time, effort, and equipment necessary to provide the servie. appear throughout CPT sections to clarify the assignment of codes.
What happens if proper coding procedures are not used?Coding Errors May Lead to Fraud and Abuse Fines
Practices and providers who have a history of coding mistakes may face fines and or federal penalties for fraud or abuse.
When a service is rendered that is not listed in the CPT codebook?CPT
What coding system is used to report services and procedures?CPT® (Current Procedural Terminology)
The CPT coding system describes how to report procedures or services. The CPT system is maintained and copyrighted by the American Medical Association. Each CPT code has five digits.
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