Working with a diabetes educator can reduce the time physicians need to spend with each patient and increase efficiency. The term ‘incident to a physician‘s professional services means that the service was furnished as an integral, although incidental, part of the physician‘s personal professional service in the course of diagnosis or treatment of an injury or illness. Physician supervision of the diabetes educator is a key component of ‘incident to’ billing, particularly for non-certified diabetes educators.
In the physician‘s office, ‘incident to’ services must be part of the patient‘s normal course of treatment. Physicians must perform an initial service, be actively involved in the course of treatment, and record this in the patient‘s record. It is not necessary for the physician to be present in the treatment room while the services are provided by the diabetes educator, but the physician must provide direct supervision and take financial responsibility for the educator. Direct supervision means being available in the office suite.
‘Incident to’ billing may be relevant for physicians practicing in states that do not provide distinct coverage for DSMT. Physicians should check with the Medicare Carrier and/or private payor to obtain additional guidance.
The CPT® code 99211 is the only E&M code used for ‘incident to’ billing available to the physician clinic‘s ancillary staff members. Some of the other codes (in the range of 99212–99499) can, however, be billed ‘incident to’ by non-physician providers (NP, PA, CNS). Please note that Medicare regulations stipulate that neither DSMT nor MNT can be provided incident to a physician‘s services when claiming the DSMT HCPCS G codes or the MNT CPT or HCPCS G codes.
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. Typically, 5 minutes are spent performing or supervising these services. For code 99211, the office or outpatient visit for the evaluation and management of an established patient may not require the presence of a physician or other qualified health care professional.
Who can bill CPT 99211:
RNs, LPNs, Mas, CNAs, MDs, Dos, NPP, Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives
Clinical staff not eligible to bill other than CPT 99211 as the physician or NPP can perform the HPI, physical exam & MDM are considered to be the part of physician work and cannot be relegated to clinical/ancillary staff.
- The patient must be an established patient
- The visit must be a face to face encounter
- Service can be billed by physicians or NPP or by clinical staff as Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified Nursing Assistant (CNA)
Code 99211 will be accepted only when documentation shows that services meet the minimum requirements for an E&M visit. For example, if the patient receives only a blood pressure check or has blood drawn, 99211 would not be appropriate. All E&M office visits follow the member’s office visit benefit; therefore, if another Procedure code more accurately describes the service, that code should be reported instead of 99211.
Because the appropriate use of Procedure code 99211 is often confusing, we offer the following guidelines. According to the Procedure Code Book, 99211 is intended for “an office or other outpatient visits for the evaluation and management of an established patient that may not require the presence of a physician.”
The key points to remember regarding 99211 are:
- The service must be for evaluation and management (E&M)
- The patient must be established, not new
- The service must be separated from other services performed on the same day.
- The provider-patient encounter must be face-to-face, not via telephone.
Examples of Office/Clinic Visits
- Diabetic counseling
- The patient recently placed on a new medication that causes weight gain. A follow-up visit is scheduled for a weight check.
- A blood pressure evaluation for an established patient whose physician requested a follow-up visit to check blood pressure.
- Refilling medication for a patient whose prescription has run out; however, the patient must be present in the office suite and physically seen by the provider
- Discussion with patient in-person following laboratory tests results that indicate the need to adjust medications or repeat order of tests
- Suture removal following placement by a different physician/physician group
Medicare will pay for medically necessary office/outpatient visits billed on the same day as a drug administration service with modifier -25 when the modifier indicates that a separately identifiable evaluation and management (E/M) service was performed that meets a higher complexity level of care than a service represented by Procedure code 99211.
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