With the ever-changing complexities around claims management and processing, most practices and physicians rely on medical coding and billing service providers to report services correctly and ensure appropriate reimbursement.

As of January 1, 2021, significant changes were made to the office and outpatient Evaluation and Management (E&M) services (CPT codes 99202-99215) for both new and established patients. While CPT code 99201 was deleted, CPT code 99211 (established patient, level 1) was retained as a reportable service.

CPT code 99211 denotes “Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician”. CPT further states that the presenting problem(s) are usually minimal and typically, 5 minutes are spent performing or supervising these services. A minimal problem is one that may not require the presence of the physician or other qualified health care professional, but the service is provided under the physician’s or other qualified health care professional’s supervision.

The American Medical Association states, “For office or other outpatient services, if the physician’s or other qualified health care professional’s time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use 99211”. However, as code 99211 does not have any other specific guidelines like the other office visit codes, there is a lot of confusion regarding its use and documentation of the services rendered. Reporting 99211 correctly can improve revenue and documentation.

Recommendations for the Appropriate Use of Code 99211

Here are important recommendations for the proper use of 99211 for an office visit:

  • Ensure that a separate E/M service has been documented: The physician should document evaluation of the patient as well as management of the patient’s care. If the visit involved only refill of the patient’s medications by the nurse and no other E/M service was provided, 99211 should not be reported
  • The supervising physician or qualified health care professional must be in the office at the time of service: To assign 99211, certain payers including Medicare, require that the supervising provider is in the office suite at the time of the appointment. However, the billing provider does not have to be in the room or to provide face-to-face services for the patient.
  • Bill the services under the supervising provider: The supervising provider has to be present in the room but does not have to provide the service. Code 99211 must be billed as if the supervising provider personally performed the service. Documentation should specify:
    • the identity and credentials of the supervising physician and the staff that provided the service
    • the degree of the physician’s involvement
    • the link between the services of the two providers
  • Prove medical necessity: When using 99211, providers should clearly document or demonstrate that an E/M service was performed and that it was medically necessary. The documentation should support the visit and ensure that the E/M service is significant and separately identifiable from other services provided that day.

Prior to the pandemic, code 99211 could be used only for an established patient. CPT defines an established patient as one who has received professional services from the physician or another physician of the same specialty in the same group practice within the past three years. The established-patient rule also is important since Medicare applies the concept of incident-to services for 99211. Incident-to services are provided by a non-physician practitioner (e.g., RN). The provider must have initiated the service as part of a continuing plan of care, and the 99211 service provided is an incidental part of that care plan.

However, it must be noted that CMS updated their rule after the COVID-19 pandemic, noting that providers performing COVID-19 specimen collection could bill 99211 for new and established patients during the public health emergency (https://s3.amazonaws.com/cdn.smfm.org). The AMA has published a document with various scenarios when collecting COVID-19 specimens, including the use of the 99211.

When Code 99211 cannot be Billed

On their site, health insurer EmblemHealth lists specific services that cannot be reported using code 99211. Physicians and staff should not use this code to bill for:

  • Administering routine medications by physician or staff whether or not an injection or infusion code is submitted separately on the claim
  • Checking blood pressure when the information obtained does not lead to management of a condition or illness
  • Drawing blood for laboratory analysis or for a complete blood count panel, or when performing other diagnostic tests whether or not a claim for the venipuncture or other diagnostic study test is submitted separately
  • Faxing medical records
  • Making telephone calls to patients to report lab results or to reschedule patient procedures
  • Performing diagnostic or therapeutic procedures (especially when the procedure is otherwise usually not covered/not reimbursed, or payment is bundled with reimbursement for another service) whether or not the procedure code is submitted on the claim separately
  • Recording lab results in medical records
  • Reporting vaccines
  • Writing prescriptions (new or refill) when no other evaluation and management is needed or performed

It’s important that medical coding service providers educate clinicians about ensuring accurate documentation for appropriately reporting 99211 services. This will also ensure a more beneficial medical record for all clinicians involved in the care of the patient.