JenniferT_62645
New member
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?
Should the nurses also be assessing the patient's pain level and documenting both pre and post-procedure vital signs as a minimum?