Ob-Gyn E/M Coding and Code 99211: The Do’s and Don’ts

The evaluation and management (E/M) codes requirements have become more specific over the years, barring – 99211 (CPT’s level-I established patient encounter code). According to CMS, the E/M audits revealed a continuous abuse of code 99211. Physicians are still struggling to appropriately report this code, and offices are repeatedly misusing it for any service that a nurse provides. Your ob-gyn coding could be costing your practice deserved reimbursement, due to failure in charging for simple patient visits with a nurse.

CPT® defines 99211 as an Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional, and it also states the presenting problem(s) are minimal, and typically, 5 minutes are spent performing or supervising these services.

Key Points to Remember for Reporting code 99211:

  • The patient is established: Code 99211 cannot be reported for services provided to patients who are new to the physician. An established patient refers to 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.
  • Face to Face Encounter: The provider-patient encounter has to be face-to-face. Telephone calls with patient do not qualify for reporting code 99211
  • CMS warns you must document medical necessity: All nurse visits do not warrant reporting code 99211. For instance, a patient comes into the office for a blood pressure check because he recently had a high BP reading. Today’s reading is normal. Reporting 99211 would be appropriate for this service. However, suppose a patient phones your office to report that he misplaced the dressing material the doctor had provided. He also reports that his BP readings at home for the last week were normal. He returns to your office with his readings. The nurse hands him new dressings, takes the readings, and puts them into the patient’s record. In this case, reporting 99211 would be wrong because the nurse simply hands him the new material and accepts the readings.
  • An actual E/M visit must be provided, which means a limited physical assessment is performed on the patient or that the patient’s history is reviewed. CPT Code 99211 should not be reported if a clinical need is not substantiated. For instance, when a patient comes into the office just to pick up a routine prescription does not qualify using code 99211.
  • Note: If another CPT® code more accurately describes the service being provided, that code should be used instead of 99211. For instance, if a physician instructs a patient to come to the office to have blood drawn for routine labs, the lab technician should report CPT® code 36415 (routine venipuncture) instead of 99211 since an E/M service was not required.

Code 99211 should not be reported to bill for:

  • When physician gives patient orders over the phone
  • Checking vital signs such as temperature and BP when the information obtained does not lead to management of a condition or illness
  • Physician calls in prescription refill to the pharmacy
  • Writing prescriptions (new or refill) when no other evaluation and management is needed or performed
  • Staff calling patients to report lab results or to reschedule patient procedures
  • Staff faxing medical records
  • Administering routine medications by physician or staff whether or not an injection or infusion code is submitted separately on the claim
  • Performing 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
  • Staff recording lab results in medical records

For more guidance on E/M coding, billing and documentation issues, check out our expert speaker Jan Rasmussen, CPC, ACS-GI, ACS-OB in this webinar HERE.

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