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: info@medicalbillersandcoders.com or call us at: 888-357-3226.
FAQs:
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.
