Confused about when to code CPT 99211 for established patients? This guide clarifies its use, including “incident to” services, documentation tips, and more.
CPT 99211 is defined as “Office or other outpatient visit 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.”
Very little official documentation guidance has been published for CPT 99211. Unlike the other E&M codes, history, exam, and medical decision making are not required. However, CPT 99211 remains an Evaluation & Management service and requires both evaluation AND management elements.
Evaluation ─ The record must include documentation of a clinically relevant and necessary exchange of information (historical information and/or physical data).
Management ─ Patient care must be directed, or re-directed, as a result of a data exchange.
A physician does not need to be in the exam room; however, you must justify information in the medical record to support the E/M code.
When to bill 99211:
• “Incident to” services are provided. The provider must place an order in the patient’s medical record that he ordered the patient to come back.
• The patient must be established.
• The patient encounter must be face to face.
• The service must be separate from other services performed on the same day.
• It must be an established diagnosis.
Documentation should include the following:
• Sufficient information to support the reason for the encounter and E/M service
• Any relevant history
• Physical assessment and plan of care
• The date of service
• The identity of the person providing care
• Any interaction with the supervising physician or other practitioner
| Service Provided | What was documented?* | Should service be billed as 99211? |
|---|---|---|
| Venipuncture (36415): Asymptomatic | • Pt here for lab draw only • No vitals or other symptoms were discussed • Provider simply notes and signs off on documentation | No Bill for blood draw only. Blood draws do not require the provider’s presence in the office. |
| Blood Pressure Check | • BP reading and any other pertinent vital signs • Clinical reason pt. was being checked for BP • RN reviews with provider • Provider reviewed and made any necessary recommendations for further treatment. • Provider signs off • Provider did not physically see the patient | Yes Documentation clearly explains medical necessity of this service. |
| Blood Pressure Check | • Patient comes to the office to pick up medication • Since they are there, they ask if they can have their blood pressure checked | No There is no order for the blood pressure check. It is just a courtesy check. |
| Immunizations or Vaccines | • Pt here for any vaccines that are due, including flu, pneumonia, tetanus, well child vaccines, etc. • Patient does not have any other needs • Provider simply notes and signs off on documentation | No Only the administration of the vaccine and the biologic is billable. CPT code 99211 is not separately reportable with vaccine administration codes 90460-90474, or G0008-G0010 per the National Corrective Coding Initiative. |
| Medication Management | • Patient here to have you fill up pill box • Documented pill box was filled | No No form of an E&M was documented. No order was provided by the provider |
| Medication Management | • Refilling medication for a patient whose prescription has run out • Patient must be present • You documented that you went over complications they may have from the prescriptions • You documented you went over the side effects and addressed the patient’s concerns about the medication | Yes The order from the doctor indicates that this visit was incident to the doctor’s plan. The patient had a face to face with the nurse. |
| Lab Results | • In-person discussion with patient following laboratory tests results that indicate the need to adjust medications or repeat tests • Document what was discussed in regard to lab results • Document adjustment of medication | Yes |
| Family Planning | • Patient came in for Depo injection • There is an order from the provider | No The administration code for the depo (96372) covers the services provided (side effects, concerns) |
| Family Planning | • Patient came in for contraception • There is an order from the provider for the patient to come back so the patient can be evaluated on how they are doing with their contraception • A pregnancy test is provided • The nurse documents questions about issues such as weight gain or how they are feeling with their current contraception method • Vitals are taken and documented | Yes The order from the provider shows this visit was incident to the doctor’s plan. The patient had a face-to-face with the nurse. |
| TB test (PPD) | • The patient comes in for a TB test • Document that the test was given | No The TB (PPD) code includes the administration. |
| TB (PPD) Read | • The patient comes in for a reading of the results for TB (PPD). • Document the results | Yes There is not another code to describe the read, so you can bill 99211. |
| Wound Care | • Suture removal following placement by a different physician/physician group | Yes |
| Wound Care | • Dressing change for an abrasion/injury | Yes |
| Wound Care | • Visits for the sole purpose of routine dressing changes | No |
| Diabetic counseling | • Visit to check blood glucose, diet and exercise. • Document the results from the blood check • Document diet and exercise plan. | Yes (RN , not pharmacist, can use the 99211) |
Contact CodeEMR with questions about professional fee coding, CPT coding, or ICD coding, CodeEMR’s medical coding services provide medical coding solutions to meet evolving needs.
For more information, fill out this brief form, and we will get back to you.
