CPT code 99211 - definition and how to use.

CPT code 99211© is used to report a low-level Evaluation and Management (E/M) service. The CPT book defines code 99211 as:

“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/M CPT codes, the CPT book 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.”

CPT 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.

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  ualified health care professional.

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.


Among other things, code 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.

• 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.

Billing and Coding Guidelines


Carriers must advise physicians that CPT code 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 than CPT code 99211) is performed, in addition to one of these drug administration services, the appropriate E/M CPT code 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.

For drug injection codes furnished prior to January 1, 2004, the carrier paid separately for the drug injection code only if no other physician fee schedule service was being paid at the same time. If CPT code 99211 was billed with a drug injection code, the carrier paid only for 99211.

If code 99211 is billed with a drug injection code (90782 to 90788), the carrier shall pay only code 99211.

Office visit CPT code 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

Added CPT 99211 may not be separately reimbursable with many chemotherapy, therapeutic, or vaccine administration codes.

2 comments:

medical billing and coding information said...

Thanks for the info - it's always good to refresh your memory on what the different codes mean and how they should and shouldn't be used.

Anonymous said...

I highly agree with you on this.

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