Medical document requirement for cpt code 99211

Documentation Requirements for CPT Code 99211

The table below contains elements that would constitute adequate documentation of a code 99211 service in selected clinical circumstances:

Blood pressure check

1. Blood pressure and other vital signs recorded.
2. Clinical reason for checking blood pressure recorded (i.e., follow up to previous abnormal finding, symptoms suggestive of abnormal blood pressure, etc).
3. Current medications listed (with notation of level of compliance).
4. Indication of doctor’s evaluation of the clinical information obtained and his management recommendation.
5. Identity and credentials of provider(s) as listed in text above.

Prescription refill or injection/infusion

1. Reason for the visit. A physician visit is not necessary to routinely provide stable patients with an ongoing medication supply. Therefore, the documentation for code 99211 or any other E/M code in this circumstance must demonstrate a need for clinical evaluation and management (for instance, symptoms or signs reported that are significant enough to necessitate evaluation).
2. Current medications listed (with notation of level of compliance).
3. Indication of doctor’s evaluation of the clinical information obtained and his management recommendation.
4. Identity and credentials of provider(s) as listed in text above.


Prothrombin time evaluation for patients on chronic warfarin anticoagulation




1. Reason for the visit. A physician visit is not routinely necessary to draw blood for prothrombin time or other laboratory tests. Therefore, the documentation for code 99211 or any other E/M code in this circumstance must demonstrate a need for clinical evaluation and management. In this case, services that would serve to demonstrate that evaluation and management was performed include an evaluation of significant new symptoms (such as excessive bruising or hemorrhage). Alternatively, for patients who have no new clinical concerns, documentation that contemporaneous laboratory values were obtained, reviewed, and used to guide current and/or future therapy documents that a separately payable E/M service has been performed.
2. Current medications listed (with notation of level of compliance).
3. Indication of doctor’s evaluation of the information about signs/symptoms and laboratory test result and his management recommendation.
4. Identity and credentials of provider(s) as listed in text above.

1 comment:

Anonymous said...

I see that you have to do vitals on a patient to charge the 99211 do you have to do the vitals on a 99391-99394?

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