CPT code 99211 - Billing Guide, office visit documentation - Medical billing cpt modifiers and list of Medicare modifiers. (2022)

Procedure code and description



99211 – 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. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.

average fee amount – $25 – $40


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.


Appropriate Use of Procedure Code 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 visit 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.

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.


Examples of office/clinic visits generally billable using 99211:

• Patient recently placed on a new medication which causes weight gain. A follow-up visit is scheduled for 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, patient must be present in 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

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• Suture removal following placement by a different physician/physician group

• Visit for instructions/patient education on how to use a peak flow meter and other devices

• Diabetic counseling

• Dressing change for an abrasion/injury

Examples of services generally not billable using 99211:

• Blood draw only—should be billed using Proceure 36415 or 36416

• Laboratory tests—the lab performing the test should bill the appropriate codes

• Monitoring of cardiology tests, such as thallium stress tests, where such monitoring is inherent in the performance of the
test

• Injection of therapeutic and/or diagnostic medication—use Proceure drug administration code and drug supply code (J code). Note: Part D drugs include the administration fee and must be billed directly to Medicare plan.

• Vaccinations/Immunizations—bill immunization Proceure code (e.g., Flu 90658) and administration Proceure code only (e.g., 90471)

CPT code 99211 - Billing Guide, office visit documentation - Medical billing cpt modifiers and list of Medicare modifiers. (1)

Appropriate usage of CPT 99211

CPT 99211 define as “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. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.”

(Video) Introduction to CPT Modifiers

Guidelines:

▪ Patient must be an established patient
▪ 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)

Who Typically Uses 99211?

Employed staff members as follows:
▪ RNs
▪ LPNs
▪ MAs
▪ CNAs

The above clinical staff‘s must bill CPT 99211 under supervising Physician or NPP under ‘‘incident to’’ billing guidelines..

Who Else Can Assign 99211?
▪ MDs, DOs
▪ NPP
o Nurse Practitioners
o Physician Assistants
o Certified Nurse Midwives

Note: Note: 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



Here’s a tip for billing code 99211: the presenting problem or problems should be minimal. Typically, five minutes are spent performing or supervising services such as blood pressure checks.

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 servicerepresented byProcedurecode 99211

Carriers must advise physicians thatProcedurecode 99211 cannot be paid if it is billed with a drug administration service such as a chemotherapy or non-chemotherapy drug infusion service (effective January 1, 2004). This drug administration policy was expanded in the Physician Fee Schedule Final Rule, November 14, 2004, to also include a therapeutic or diagnostic injection code (effective January 1, 2005). Therefore, when a medically necessary, significant, and separately identifiable E/M service (which meets a higher complexity level thanProcedurecode 99211) is performed, in addition to one of these drug administration services, the appropriate E/MProcedurecode should be reported with modifier -25. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required.


commercial insurance policy billing with Injection codes

Procedure99211: E/M service code 99211 will not be reimbursed when submitted with a diagnostic or therapeutic Injection code, with or without modifier 25. This very low service level code does not meet the requirement for “significant” as defined byProcedure, and therefore should not be submitted in addition to the procedure code for the injection.


Office visit CPT code with allergen codes


99211 is not usually separately reimbursed when submitted with CPT codes 95115-95117 (allergen immunotherapy). An E/M service code should be reported
with the allergen immunotherapy codes only if a significant separately identifiable E/M service is performed, per the Current Procedure Terminology (CPT) 2011 Professional Edition



Will Oxford separately reimburse for an office E/M service when provided in other than POS 19, 21, 22, 23, 24, 26, 51, 52, and 61 if a significant, separately identifiable E/M service is performed in addition to the therapeutic or diagnostic Injection given on the same date of service by the Same Individual Physician or Other Health Care Professional?

A: Yes, Oxford will separately reimburse for an E/M service (other thanProcedure99211) unrelated to the physician work associated with the Injection service (Procedure96372-96379) when reported with a modifier 25. Refer to Q&A #2 for a description of the physician work typically included in the allowance for the therapeutic and diagnostic Injection service. When an E/M service and an Injection or Infusion service are submitted for the same enrollee on the same date of service, there is a presumption that the E/M service is part of the procedure unless the physician identifies the E/M service as a separately identifiable service.



Example: The following example describes an E/M service that is separately identifiable from a therapeutic and diagnostic Injection: A physician evaluates a patient’s symptoms, diagnoses a serious streptococcal infection, and treats with injectable penicillin. The diagnostic process is separately identifiable from the process of the injection. The E/M service (other thanProcedurecode 99211) should be reported with modifier 25 and is reimbursed separately from the therapeutic Injection code and the drug code for the penicillin.


Documentation Requirements forProcedureCode 99211

Procedure code 99211 is used to report a low-level Evaluation and Management (E/M) service. TheProcedurebook defines code 99211 as:

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“Office or other outpatient visits for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.”

Code 99211 requires a face-to-face patient encounter; however, when billed as an “incident to” service, the physician’s service may be performed by ancillary staff and billed as if the physician personally performed the service. For such instances, all billing and payment requirements for “incident to” services must be met.

As with all services billed to Medicare, code 99211 services must be reasonable and necessary for the diagnosis or treatment of an illness or injury. Unlike the other E/MProcedurecodes, theProcedurebook does not specify completion of particular levels of work for code 99211 in terms of key components or contributory factors. Also, unlike the other E/M codes, CMS did not provide documentation requirements for code 99211 in the “E/M Documentation Guidelines.”

Procedure code 99211 describes a service that is a face-to-face encounter with a patient consisting of elements of both evaluation and management. The evaluation portion of code 99211 is substantiated when the record includes documentation of a clinically relevant and necessary exchange of information (historical information and/or physical data) between the provider and the patient. The management portion of code 99211 is substantiated when the record demonstrates influence by the service of patient care (medical decision-making, provision of patient education, etc.). Documentation of all code 99211 services must be legible and include the identity and credentials of the individual who provided the service.

For code 99211, services performed by ancillary staff and billed by the physician as an “incident to” service, the documentation should also demonstrate the “link” between the non-physician service and the precedent physician service to which the non-physician service is incidental. Therefore, documentation of code 99211 services provided “incident to” should include the identity and credentials of both the individual who provided the service and the supervising physician. Documentation of a code 99211 service provided “incident to” should also indicate the supervising physician’s involvement with the patient care as demonstrated by one of the following:

• Notation of the nature of involvement by the physician (the degree of which must be consistent with clinical circumstances of the care).

• Documentation from other dates of service that establishes the link between the services of the two providers.

• Medicare has reviewed numerous claims on which 99211 was reported inappropriately. All 99211 services for which supporting documentation does not demonstrate that an E/M service was performed and was necessary as outlined in this document will be denied upon review.



Procedurecode 99211 should not be used to bill Medicare:

• For phone calls to patients.

• Solely for the writing of prescriptions (new or refill) when no other E/M is necessary or performed.

• For blood pressure checks when the information obtained does not lead to management of a condition or illness.

• When drawing blood for laboratory analysis or when performing other diagnostic tests, whether or not a claim for the venipuncture or other diagnostic study test is submitted separately.

(Video) How to code for Modifers in CPT Medical coding with examples

• Routinely when administering medications, whether or not an injection (or infusion) code is submitted on the claim separately.

• For performing diagnostic or therapeutic procedures (especially when the procedure is otherwise usually not covered/not reimbursed or payment is bundled with payment for another service), whether or not the procedure code is submitted on the claim separately.

CPT 99211, when billed for debridement, is not routinely a skilled service, therefore, not routinely covered.

Visits for the sole purpose of routine dressing changes are noncovered.

Debridement will not be considered a reasonable and necessary procedure for a wound that is clean and free of necrotic tissue or other tissue that limits wound healing.

The routine application of a topical or local anesthetic does not elevate the service to debridement

RN and qualified ancillary staff – billable E&M services

Providers can bill 99211 for RNs or qualified ancillary staff that is employed by a physician’s office as follows:

• When the patient visit is a part of an established physician care plan requiring follow-up and is deemed medically necessary.

• RNs or qualified ancillary staff cannot code higher than a 99211 for E&M services regardless of the time spent or level of services provided.

• RNs or qualified ancillary staff cannot bill new problems or new patient visit code 99201.

• A provider and an RN or qualified ancillary staff cannot both bill for an E&M office visit within the same day. Only one E&M service per day can be billed by one provider type.

FAQs

What is the CPT code 99211? ›

CPT defines this code 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.” It further states that the presenting problems are usually minimal, and typically five minutes are spent performing or supervising these services.

What is 59 modifier used for? ›

Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.

What is the CPT code 99024? ›

99024 - Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure. • Applies to surgeries with 90 and 10 day global periods.

Can 99211 be billed? ›

Using code 99211 to bill an 'incident to' service

Documentation should include the identity and credentials of the supervising physician and the staff that provided the service. Notes should indicate the degree of the physician's involvement and document the link between the services of the two providers.

Does CPT code 99211 need a modifier? ›

The use of modifier 25 requires that the key components be documented with the E&M service. Therefore, CPT code 99211 cannot be appended with modifier 25. Only the line item on the claim for CPT code 99211 appended with modifier 25 will be denied.

Does Medicare pay for CPT code 99211? ›

99211 Reimbursement Rates

Medicare will reimburse for this code at $23.03 by Medicare in 2021.

When to use 59 or 51 modifier? ›

While modifier 51 and 59 both apply to additional procedures performed on the same date of service as the primary procedure, modifier 51 differs from modifier 59 in that it applies to procedures that may be more commonly expected to be performed during the same session.

When should modifier 51 be used? ›

Use modifier 51 on the second and subsequent operative procedures when the procedures are ranked in RVU order. Modifier 51 may also be used when multiple procedures coded in the Medicine chapter of CPT (medical procedures) are performed at the same session or when surgical and medical procedures are performed together.

Which modifier goes first 26 or 59? ›

Always add 26 before any other modifier. If you have two payment modifiers, a common one is 51 and 59, enter 59 in the first position.

What is a 99213 office visit? ›

Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making.

What is modifier 24 used for? ›

Use CPT modifier 24 for unrelated evaluation and management service during a postoperative (global) period. The global period of a major surgery is the day prior to, day of and 90 days after the surgery.

Does CPT code 99024 need a modifier? ›

Post-operative visits should be reported with CPT code 99024 when the visit is furnished on the same day as an unrelated E/M service (billed with modifier 24).

Can you bill 99211 when the doctor calls in prescription refills to the pharmacy? ›

The provider-patient encounter must take place face to face.

You may not bill code 99211 for calling the patient, writing a prescription, “calling in” a prescription to the pharmacy, or e-mailing a patient.

Can you bill 99212 for a nurse visit? ›

If the patient is an established patient, you may use 99211 to 99214 depending on the level of care rendered, degree of documentation or the amount of time spent.

Can you bill 99211 for dressing change? ›

If the dressing change is performed by nursing staff under incident-to conditions, you may use code 99211. When performed by a physician, dressing changes for burns and debridement of burn tissue should be reported using codes 16020–16030, depending on the size of the burn.

What modifier is used with 99211? ›

CMS states, when a separately identifiable E/M service (which meets a higher complexity level than CPT code 99211) is performed, in addition to drug administration services, you should report the appropriate E/M CPT code reported with modifier -25.

Can modifier 25 be billed 99211? ›

Modifier 25 used by a physician other than the physician performing the procedure. Documentation shows the amount of work performed is consistent with the level of effort normally performed and is not a significant, separately identifiable E/M service. Modifier 25 should not be reported on procedure code 99211.

Is modifier 25 a payment modifier? ›

According to Medicare: Modifier 25 is used to facilitate billing of E/M services on the day of a procedure for which separate payment may be made. It is used to report a significant, separately identifiable E/M service by the same physician on the day of a procedure.

Are vitals required for 99211? ›

Taking Patient Vitals

For example, if the patient comes into a Coumadin clinic for a check, you really don't need vitals. However, if the patient comes into your practice for a blood pressure check, you probably want all the vitals. Taking vitals on its own is a qualifier for billing 99211.

What CPT codes can nurses use? ›

CPT code 99211 is often called the nurse visit code.
...
Expand CPT Code 99211 Eligibility to MAs, LPNs, and Other Staff
  • Medical Assistant (MA)
  • Certified Nurse Assistant (CNA)
  • Licensed Practicing Nurse (LPN)
  • Registered Nurse (RN)
  • Nurse Practitioner (NP)
  • Physician Assistant (PA)
  • Physician (MD).
5 Mar 2020

What is the CPT code for a nurse visit? ›

To support the 99211 code for a nursing visit, a practice must have sufficient documentation.

What is the 52 modifier used for? ›

This modifier is used to report a service or procedure that is partially reduced or eliminated at the physician's discretion.

What modifier goes first 50 or 51? ›

You should list the most resource-intense (highest paying) procedure first, and append modifier 51 to the second and subsequent procedures. Use modifier 51 to indicate: Same procedure, different sites. Multiple operation(s), same operative session.

What is a 26 modifier used for? ›

Modifier 26 is appended to billed codes to indicate that only the professional component of a service/procedure has been provided. It is generally billed by a physician. Services with a value of “1” or “6” in the PC/TC Indicator field of the National Physician Fee Schedule may be billed with modifier 26.

Can you use modifier 51 with Medicare? ›

Note: Medicare doesn't recommend reporting Modifier 51 on your claim; our processing system will append the modifier to the correct procedure code as appropriate.

What is the difference between modifier 50 and 51? ›

Modifier 50 Bilateral procedure describes procedures or services that take place on identical, opposing structures (e.g., shoulder joints, breasts, eyes). Use modifier 51 Multiple procedures to show that the same provider performed multiple procedures (other than E/M services) during the same session.

What is a 58 modifier used for? ›

Submit CPT modifier 58 to indicate that the performance of a procedure or service during the postoperative period was either: Planned prospectively at the time of the original procedure (staged); More extensive than the original procedure; or. For the therapy following a surgical procedure.

When to use 52 or 53 modifier? ›

Depending on the circumstances as to why the procedure was stopped, modifier 52 is reportable if no anesthesia was administered and the physician elected to terminate the procedure. However, modifier 53 would be applicable if anesthesia was administered and the procedure was terminated due to extenuating circumstances.

What is the 26 modifier for Medicare? ›

Modifier 26 is defined as the professional component (PC). The PC is outlined as a physician's service, which may include technician supervision, interpretation of results and a written report. Use modifier 26 when a physician interprets but does not perform the test.

What is a 25 modifier used for in medical billing? ›

Modifier 25 is defined as a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service.

What modifier is used for 99213? ›

If the circumstance calls for a Level 3 established patient visit (CPT code 99213) to be billed with psychological testing (such as CPT code 96101), modifier 59 would be appended to the testing code.

What is the difference between 99214 and 99213? ›

For example, if the total duration of face-to-face physician-patient time is 21 minutes, select code 99214 because the duration of visit is closer to 25 minutes, the average time for a 99214, than it is to 15 minutes, the average time for a 99213.

What is a 99214 office visit? ›

CPT® code 99214: Established patient office or other outpatient visit, 30-39 minutes. As the authority on the CPT® code set, the AMA is providing the top-searched codes to help remove obstacles and burdens that interfere with patient care.

What is the 27 modifier used for? ›

The CPT defines modifier –27 as “multiple outpatient hospital evaluation and management encounters on the same date.” HCFA will recognize and accept the use of modifier –27 on hospital OPPS claims effective for services on or after October 1, 2001.

What is 23 modifier used for? ›

Modifier 23 is used only with general or monitored anesthesia codes (CPT codes 00100- 01999). Modifier 23 is added after the primary anesthesia modifier which identifies whether the service was personally performed, medically directed or medically supervised (Modifiers AA, AD, QK, QS, QX, QY or QZ).

What is the difference between modifier 24 and modifier 25? ›

Modifier 24 refers to the evaluation and management services provided to the patient on the day of a surgical procedure unrelated to the procedure itself. Modifier 25 identifies the evaluation and management services as unique services provided on the same day by the same medical professional.

Can you use both modifier 24 and 25 together? ›

Use both the 24 and 25 modifiers. Modifier 24 because the E/M service is unrelated and during the post-op period of the surgery. Modifier 25 to show the E/M is significant and separately identifiable from the procedure.

What is a 24 modifier code? ›

Modifier 24 is defined as an unrelated evaluation and management service by the same physician or other qualified health care professional during a post-operative period.

Is modifier 25 needed for labs? ›

If a significant and separately identifiable evaluation and management service is provided to the patient in addition to the lab work, modifier -25 should be appended. This policy applies to Professional Claims.

How Much Does Medicare pay for 99212? ›

CPT Code 99212 Reimbursement Rate

Medicare reimburses for procedure code 99212 at $62.76 in 2022.

What is CPT code 87426 used for? ›

Furthermore, the code, 87426, represents antigen tests using an immunofluorescent or immunochromatographic technique for the detection of biomolecules produced by the SAR-CoV-2 virus (COVID-19). Antigen testing is intended to be easier and quicker than other COVID-19 testing.

Can a nurse bill for phone calls? ›

Answer: An RN can provide Telephone Triage calls when the RN is overseen by a physician, NP or PA. The Telephone Triage calls can be billed using CPT codes 98966-98968; the rendering requirement provider information on the claim must reflect the overseeing provider's NPI and/or Medicaid Provider ID number.

Can you bill a nurse visit for a blood pressure check? ›

Yes, blood pressure checks may be billed as a nurse visit. However, not all offices charge for this service if they are only checking blood pressure as a courtesy for a patient.

What is the CPT code for nurse visit? ›

CPT code 99211 is often called the nurse visit code. But it's not just for nurses! Many of your practice employees can provide the service. They must be qualified to evaluate and meet the patient's care needs in a limited capacity.

What documentation is required for 99211? ›

The presence of a physician is not required in the exam room. Unlike other E/M codes, CPT 99211 does not have any documentation requirements for the history, physical exam or complexity of medical decision making, however, supporting documentation in the patient record is required.

What does CPT code 99212 mean? ›

CPT® code 99212: Established patient office or other outpatient visit, 10-19 minutes.

Does 99211 require physician signature? ›

CPT defines 99211 as office or other outpatient visit for the evaluation and management of an established patient who may not require the presence of a physician.
...
Medicare 99211 Checklist.
The answer to questions 1–10 must be 'Yes'YesNo
Are all signatures, credentials, and documentation legible?
9 more rows

Can you bill a nurse visit for a blood pressure check? ›

Yes, blood pressure checks may be billed as a nurse visit. However, not all offices charge for this service if they are only checking blood pressure as a courtesy for a patient.

Can you bill 99211 for dressing change? ›

If the dressing change is performed by nursing staff under incident-to conditions, you may use code 99211. When performed by a physician, dressing changes for burns and debridement of burn tissue should be reported using codes 16020–16030, depending on the size of the burn.

What is a 99213 office visit? ›

Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making.

Can you bill 99211 when the doctor calls in prescription refills to the pharmacy? ›

The provider-patient encounter must take place face to face.

You may not bill code 99211 for calling the patient, writing a prescription, “calling in” a prescription to the pharmacy, or e-mailing a patient.

Can 99211 and 96372 be billed together? ›

Answer: You cannot ever bill 99211 with 96372. In fact, according to the Correct Coding Initiative (CCI), no modifier will separate the edit bundling these codes together, so there are no circumstances under which they can be reported together.

Can you bill 99212 for nurses? ›

A: That depends entirely on what was done and documented. In most cases, the visit would be a level one new patient visit (99201), level two established patient visit (99212), or nurse visit (99211), since only one body area is examined, and the history and/or medical decision-making are straightforward.

Does 99213 need a modifier? ›

If the circumstance calls for a Level 3 established patient visit (CPT code 99213) to be billed with a demonstration of home monitoring of a patient's international normalized ratio (e.g., HCPCS code G0248), modifier 59 would be appended to the demonstration code.

How many minutes is CPT 99213? ›

Procedure Code 99213 Time Length:

15 minutes in length, as determined by their level of risk and complexity of treatment. If a client has a more complex treatment plan requiring additional time, bill evaluation and management CPT Code 99214 or 99215 to designating higher risk and complexity of services.

Does CPT 99214 require a modifier? ›

Coding example:99214 – 2593015The physician codes an E/M visit (99214) and he also codes for the cardiovascular stress test (93015). The modifier 25 is added to the E/M visit to indicate that there was a separately identifiable E/M on the same day of a procedure. ”

How Much Does Medicare pay for 99212? ›

CPT Code 99212 Reimbursement Rate

Medicare reimburses for procedure code 99212 at $62.76 in 2022.

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3. CPT Coding for Beginners by AMCI Part 1
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4. Medical Coding - CPT code symbols, modifiers and place of service.
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5. Modifier 25 Usage in Medical Coding
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6. Discussion of CPT Code Lookup 99211
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