Resolved Documentation requirements for 99211

[JenniferT_62645]

I work on the facility side, so E/M is not my area of expertise. We have a site that is an infusion center (with on-site provider oversight) and an outside provider comes in and performs a bladder instillation of chemo . The chemo instillation procedure is billed by the provider. Our facility bills for the drug used and wants to bill an E/M for the nursing services that are provided with 99211. Currently the nurses are documenting vital signs and a sentence stating that the provider placed the catheter and completed the procedure. Our nurse auditors don't feel that this nursing documentation is sufficient to charge 99211, but I am having difficulty finding documentation requirements for 99211. We do have an office note, order, and procedure note from the provider who is performing the procedure.

Should the nurses also be assessing the patient's pain level and documenting both pre and post-procedure vital signs as a minimum?

 

[Darcy]

Six keys to coding 99211 visits​

Using CPT code 99211 can boost your practice’s revenue and improve documentation. The following guidelines can help you decide whether a service qualifies:
1. The patient must be established.
2. The provider-patient encounter must be face-to-face.
3. 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. If a clinical need cannot be substantiated, 99211 should not be reported. If another CPT code more accurately describes the service being provided, report it instead of 99211 (e.g., 36415 for a routine blood draw visit with a nurse).
4. The service must be separate from other services performed on the same day. Services considered part of another E/M service provided on the same day should not be reported with code 99211 (e.g., a nurse checks a patient’s vital signs prior to an encounter with the physician).
5. 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. Medicare’s requirements are slightly different: 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 and must be in the office suite when the service is provided.
6. No key components are required. Unlike other office visit E/M codes – such as 99212, which requires 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. 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.