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Find-A-Code Articles, Published 2021, September 28

When is it proper to bill nurse visits using 99211.

by   Christine Woolstenhulme, QMC QCC CMCS CPC CMRS Sep 28th, 2021 - Reviewed/Updated Aug 29th

When vaccines or injections are given in the office, coding can often get confusing; for example, is it correct to report a nurse visit using  99211  and an E/M office visit reporting  99202  ‑  99215  and include injection fees with the vaccine product? In addition, the reporting of evaluation and management (E/M) during the same visit where vaccines are administered is not always understood. The answer depends on whether the provider performs a medically necessary and significant, separately identifiable E/M visit, in addition to the immunization administration.

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. 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.

It is incorrect to bill a  99211  when the provider provides an E/M service that meets a higher complexity level than CPT code  99211 , you must bill the higher complexity, and you cannot bill for two services in one day. 

Charging for Nurse Visits

There are times when it is appropriate to report for a nurse visit using CPT code  99211 . The  Incident-to rule  applies when reporting this code, and services provided must be documented as medically necessary services, including the clinical history, clinical exam, making a clinical decision, and physician supervision. 

• NOTE: A nurse visit is not paid if billed with a drug administration service such as chemotherapy or non-chemotherapy drug infusion code, including therapeutic or diagnostic injection codes. The reasoning is because diagnostic IV infusion or injection services typically require direct physician supervision, and using  99211 is reported by qualified healthcare professionals other than physicians.

08/29/2023 NOTE: (These CPT codes,90782, 90783, 90784, or 90788  were deleted in 2006, but still showing in CMS - Claims processing manual) When reporting CPT codes 90782, 90783, 90784, or 90788 , CPT code 99211  cannot be reported. In addition, it is improper billing to report a visit solely for an injection that meets the definition of the injection codes. 

When the only reason for the visit is for the patient to receive an injection, payment may be made only for the injection (if it is covered). An office visit using  99211 would not be warranted where the services rendered did not constitute a regular office visit and a part of the plan of care and not at the patient's request.

Unlike other E/M codes  99202 - 99205 , and 99212 - 99215 , time alone cannot be used when reporting  99211  when selecting the appropriate code level for E/M services. Effective January 1, 2021, time was removed as an available code-selection criterion. The typical time spent on this code is five minutes.  

Other visits billed with  99211

Several other visits may be reported using  99211 , and nurses are not the only staff that can report this code; medical Assistants and technicians are also included under non-physician.  

Covid-19 Testing

According to  CMS ; Physician offices can use CPT code  99211  when office clinical staff furnish assessment of symptoms and specimen collection for Covid-19 incident to the billing professionals services for both new and established patients. When the specimen collection is performed as part of another service or procedure, such as a higher-level visit furnished by the billing practitioner, that higher-level visit code should be billed. The specimen collection would not be separately payable.

Examples from CMS

The following are examples of when  CPT  99211  might be used:

• Office visit for an established patient for blood pressure check and medication monitoring and advice. History, blood pressure recording, medications, and advice are documented, and the record establishes the necessity for the patient's visit.
• Office visit for an established patient for return to work certificate and advice (if allowed to be by other than the physician). Exam and recommendation are noted, and the Return to Work Certificate is completed, copied, and placed in the record.
• Office visit for an established patient on regular immunotherapy who developed wheezing, rash, and swollen arm after the last injection. Possible dose adjustments are discussed with the physician, and an injection is given. History, exam, dosage, and follow-up instructions are recorded.
• Office visit for an established patient's periodic methotrexate injection. Monitoring Lab tests, query signs and symptoms, obtain vital signs, repeat testing, and injection advised. All this information is recorded and reviewed by the physician. (Note that in this circumstance, if  99211  is billed, the injection code is not separately billable). An office visit for an established patient with a new or concerning bruise is checked by the nurse (whether or not the patient is taking anticoagulants), and the patient is advised on how to care for the bruise and what to be concerned about, and, if on anticoagulants, continuing or changing current dosage is advised. History, exam, dosage, and instructions are recorded and reviewed by the physician.
• Office visit for an established patient with atrial fibrillation who is taking anticoagulants and has no complaints . The patient is queried by the nurse, vital signs are obtained, the patient is observed for bruises and other problems, the prothrombin time is obtained, the physician is advised of prothrombin time and medication dose, and medication is continued at present dose with follow up prothrombin time in one month recommended. History, vital signs, exam, prothrombin time, INR, dosage, physician's decision, and follow-up instructions are recorded.

References/Resources

About christine woolstenhulme, qmc qcc cmcs cpc cmrs.

Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code.  Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.

When is it Proper to Bill Nurse Visits using 99211. (2021, September 28). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/nurse-visits-and-injections-36866.html

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Using and Documenting CPT Code 99211 Services Correctly

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Using and Documenting CPT Code 99211 Services Correctly

CPT ®  code 99211 is defined by the 2011  CPT  Standard Edition manual 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."

Using code 99211 to report a low-level evaluation and management (E/M) service   Code 99211 describes a face-to-face encounter with a patient consisting of elements of both evaluation (requiring documentation of a clinically relevant and necessary exchange of information)  and  management (providing patient care that influences, for example, medical decision making or patient education). Documentation must be legible and include the identity and credentials of the servicing provider.

Using code 99211 to bill an 'incident to' service   When Code 99211 is 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. 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.

All 99211 services that  don’t  document or demonstrate that an E/M service was performed and necessary will be denied upon review.

Code 99211 should not be used by physician or staff to bill for:

• Administering routine medications by physician or staff whether or not an injection or infusion code is submitted separately on the claim
• Checking blood pressure when the information obtained does not lead to management of a condition or illness
• Drawing blood for laboratory analysis or for a complete blood count panel, or when performing other diagnostic tests whether or not a claim for the venipuncture or other diagnostic study test is submitted separately
• Faxing medical records
• Making telephone calls to patients to report lab results or to reschedule patient procedures
• Performing diagnostic or 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
• Recording lab results in medical records
• Reporting vaccines
• Writing prescriptions (new or refill) when no other evaluation and management is needed or performed

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99211 CPT Code (2023) | Description, Guidelines, Reimbursement, Modifiers & Examples

The 99211 CPT code may be used for established patients and is defined as those treated by the provider (or another member of the same medical group and specialty in the last three years. You can’t use 99211 for a new patient . When it comes to 99211, the established-patient rule is crucial. 

Medicare uses the concept of incident-to-services, which states that an initial course of treatment initiates with the help of a provider who provided direct, professional service to that patient before giving the 99211 CPT code services.

At the time of an appointment, the supervising provider must be in the office suite to submit the code 99211 to specific payers (including Medicare). There is no need to have a billing provider in the patient’s room or to conduct face-to-face services for this provider. 

The supervising provider does not need to be the one who wrote the care plan. If you use 99211 CPT code services “incident to,” you may note the professional who gave it and the doctor who oversaw it. 

An “incident to” treatment will document the supervising physician’s engagement in the patient’s care in some form, such as by using one of the following:

• It’s critical to emphasize the nature of the doctor’s participation, whether they much or how to care
• Evidence from previous service dates suggests a close link between them.

Medicare has looked into a few incidents where the code 99211 may enter incorrectly. Upon examination, all 99211 activities for which proper documents do not prove that an E/M service may perform will reject as defined in this document. 

Appointments for established patients may require the attendance of a physician or other competent healthcare provider, or they may not necessitate their presence at all. Code 99211 specifies an “outpatient visit for the evaluation and care of an established patient that may not require the presence of a physician,” as CPT defines.

 According to CPT’s findings, 5 minutes may spend conducting or supervising these services. It is a small problem if it does not demand the presence of a physician or other competent healthcare professional, but the therapy administers under their supervision.

American Medical Association: “If the physician or other qualified health care professional’s time may  spend overseeing clinical employees who conduct the face–to–face services in an encounter, use 99211 CPT code.” 

99211 CPT Code | Description

According to CPT, there are two types of established patients: those with a history of receiving technical advice from one practitioner and those without.

For the 99211 CPT code, Medicare uses “incidental services,” and established patients are critical. A non-physician practitioner performs services unrelated to the patient’s primary care (e.g., RN). Providing the 99211 services was a byproduct of the provider’s larger long-term care strategy.

CPT® code 99211 is defined as follows in the 2011 CPT Standard Edition handbook:

“It is common for minor issues to cause the visit. It usually takes less than five minutes to provide or monitor these tasks”.

Evaluating and managing a patient in person include documenting clinically relevant and essential information exchange.

For the documentation to be understandable, it must include information about the service provider, including their name and qualifications. For “incident to” services, an auxiliary staff member may favor the physician, and the physician’s charge will reflect that.

 It is essential to identify and credential the doctor who supervised the treatment and the medical professionals who performed it. There will be no acceptance of any service that does not show or prove that an E/M service was completed and is necessary.

 Regular drugs are provided by doctors and staff members regardless of what an injection or infusion code is stated separately on the claim. 

99211 CPT code will  use by clinicians or labor to bill for the following items:

• Blood pressure may check to see if the information gained helps control the disease.
• Payment for blood samples may obtain, or a similar diagnostic research test will submit separately from a claim for blood collection for laboratory examination, a complete blood cell screen, or other diagnostic tests.
• Diagnoses and treatments that aren’t generally covered or reimbursed (especially when payment may couple with reimbursement for another service) can perform. 

Billing Guidelines

Two of the most significant recorded portions of all resolved office patient charge codes define the suitable administration level (99211-99215). In contrast, new patients’ consideration experiences in the office must meet the requirements of the three most frequently raised parts described above (99201-99205).

 Only the top two-thirds of sections should be able to establish whether or not CPT® 99213 warrants further study. The following test may design to assess your knowledge of the prerequisites necessary to pass the CPT 99213 exam. 

Eye-to-eye contact is essential in all E/M events, as it always has been. Codes for outpatient centers allow Medicare to bill for episodes the administration may provide by someone other than the doctor. 

Depending on the situation’s specifics, the doctor may be able to bill for the whole amount. The administration billed the incident to the doctor’s supplier number. It’s a medical coding number, 99213. As a whole, the issue’s history. 

Only 1-3 elements may need the historical context of the current illness (HPI) or the status of three ongoing restorative conditions (HPI). Therapeutic, social, and familial histories may require for admission. 

Preventative care includes Pap Smears , which detect abnormalities in the cervical tissue. Visit the office (99211 CPT code), and 95115-95117 are incompatible (allergen immunotherapy). Mutually exclusive services are not eligible for separate reimbursement. 

Preventive and routine doctor’s visits will consist of this category. Counseling and care coordination are essential in determining eligibility for E/M services if it accounts for more than half of the physician’s patient and family contact (in the office or other outpatient environment).

99211 CPT code for outpatient care may provide in a clinic or another outpatient facility to established patients who do not take place in the presence of a clinician or other licensed health care practitioner.

Problems presented are typically minimal. The average time to provide or monitor these services is five minutes. Billing instructions instruct that the bill one unit for each visit.

How To Use Modifiers With The 99211 CPT Code

Only established office visits (99211-99215) billed with modifier -25 are payable with treatments when there are two separate diagnoses on the claim and the billing expert is a dermatologist. 

E&M services invoiced with Current Procedural Terminology (CPT®) code 99211 and modifier 25 on or after March 16, 2020, will be denied reimbursement if they bill alone or with another procedure code on the same day the service was performed.

For a low-level E&M visit that does not need the presence of a physician or the recording of essential components, CPT code 99211  may use to bill for the history, examination, and physician prescription. Modifier 25 mandates the medical facility service to document all crucial details.

In this case, just the CPT code 99211 with modifier 25 will reject. We will amend our reimbursement policy for evaluation and management services to reflect this change.

E/M service code 99211 may not compensate for diagnostic and therapeutic purposes. The procedure’s definition of “major” does not include this low service level code. Hence it will not give in addition to the procedure code.

Drug administration services, such as chemotherapy or non-chemotherapy drug infusion, should not be billed with Procedure Code 99211, and carriers should alert providers (effective January 1, 2004).

 On November 14, 2004, the FDA added a therapeutic or diagnostic injection code to its policy as part of the Clinician Fee Schedule Final Rule. At this point (January 1, 2005).

Medically essential, significant, and distinct E/M services (that meet a higher level of complexity than Procedure 99211 CPT code) may perform in addition to one administration service, and E/M Procedure codes will report with modifier -25.

Documentation is required to prove the level of E/M service charged. If an E/M service will provide on the same day, a new diagnosis is unnecessary. Having a physician present for an outpatient appointment for an established patient’s evaluation and management does not need their presence.

These services take five minutes to provide or monitor, costing between $25 and $40 per hour. Code 99211 office or outpatient appointments for existing patients do not require the presence of a physician or other registered health care practitioner.

Reimbursement

In cases where the operation is not otherwise covered/reimbursed, or payment may bundle, whether or not a single procedure code can submit on the claim for clinical procedures. In 2021, Medicare will pay $23.03 for this code.

Inappropriate Usage

Don’t use CPT 99211 to bill Medicare for phone calls to patients.

Don’t report CPT 99211 to bill Medicare solely for writing prescriptions (new or refill) when no other evaluation and management is necessary or performed.

Don’t use the 99211 CPT code to bill Medicare for blood pressure checks when the information obtained does not lead to managing a condition or illness.

Don’t report CPT 99211 to bill Medicare when drawing blood for laboratory analysis or when performing other diagnostic tests, whether a venipuncture or other diagnostic study test is submitted separately.

Don’t use CPT 99211 to bill Medicare when drawing blood for laboratory analysis for anti-coagulation monitoring and no face-to-face counseling occurs with the beneficiary, even if a results later that day are called to the beneficiary.

Don’t report the 99211 CPT code for face to face counseling that is provided without a medical need for such counseling; i.e., provided solely because the patient comes for laboratory testing.

Don’t report CPT 99211 to bill Medicare routinely when administering medications whether or not an injection (or infusion) code is submitted separately.

Billing Examples

Below are billing examples for the 99211 CPT code.

Please arrive at the office of a long-term orthodontics patient who complains of a wire irritating their face and asks that you check it out. orthodontists and maxillofacial surgeons 

During an allergy vaccine injection, a 20-year-old female patient observes by a nurse for any reaction signs. (Otolaryngology/Head and Neck Surgery)

A 45-year-old man with chronic renal failure may see at the office for the supply of erythropoietin. (Nephrology)

Patient: A Peace Corps volunteer visits the office and asks for proof that her third molar will remove. She is already an established patient. Dentists and Maxillofacial Surgeons

Treatment of an established female patient, 69 years old, by removing some antibiotic gauze from an infected wound site. (Plastic surgery)

Office visit for an 82-year-old female, established patient for a monthly B12 injection with documented Vitamin B12 deficiency. (Geriatrics/Internal Medicine/Family Medicine)

Office visit for a 50-year-old male, established patient, to remove uncomplicated facial sutures. (Plastic Surgery)

Office visit for an established patient who lost a prescription for lichen planus; returned for new copy. (Dermatology)

Office visit for an established patient undergoing orthodontics who complains of a wire irritating his/her cheek and asks you to check it. (Oral & Maxillofacial Surgery)

Office visit for a 50-year-old female, an established patient, seen for her gold injection by the nurse. (Rheumatology)

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Appropriate Use of CPT Code 99211

Working with a diabetes educator can reduce the time physicians need to spend with each patient and increase efficiency. The term ‘incident to a physician‘s professional services means that the service was furnished as an integral, although incidental, part of the physician‘s personal professional service in the course of diagnosis or treatment of an injury or illness. Physician supervision of the diabetes educator is a key component of ‘incident to’ billing, particularly for non-certified diabetes educators.

In the physician‘s office, ‘incident to’ services must be part of the patient‘s normal course of treatment. Physicians must perform an initial service, be actively involved in the course of treatment, and record this in the patient‘s record. It is not necessary for the physician to be present in the treatment room while the services are provided by the diabetes educator, but the physician must provide direct supervision and take financial responsibility for the educator. Direct supervision means being available in the office suite.

‘Incident to’ billing may be relevant for physicians practicing in states that do not provide distinct coverage for DSMT. Physicians should check with the Medicare Carrier and/or private payor to obtain additional guidance.

The CPT® code 99211 is the only E&M code used for ‘incident to’ billing available to the physician clinic‘s ancillary staff members. Some of the other codes (in the range of 99212–99499) can, however, be billed ‘incident to’ by non-physician providers (NP, PA, CNS). Please note that Medicare regulations stipulate that neither DSMT nor MNT can be provided incident to a physician‘s services when claiming the DSMT HCPCS G codes or the MNT CPT or HCPCS G codes.

Office or other outpatient visits 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. 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.

Who can bill CPT 99211:

RNs, LPNs, Mas, CNAs, MDs, Dos, NPP, Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives

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.

• The patient must be an established patient
• The 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)

Appropriate Use

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.

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 visits 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.

Examples of Office/Clinic Visits

• Diabetic counseling
• The patient recently placed on a new medication that causes weight gain. A follow-up visit is scheduled for a 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, the patient must be present in the 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
• Suture removal following placement by a different physician/physician group

Modifier 25

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 service represented by Procedure code 99211.

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What Services Are Included in the Immunization Administration Codes?

• Relative Values of Immunization Codes*

What Additional Services Are Required to Appropriately Report 99211?

What are the documentation requirements for 99211, coding information from cpt and the cms, coding examples, vignette #1, vignette #2, vignette #3, when is it appropriate to report 99211 during immunization administration.

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American Academy of Pediatrics Committee on Coding and Nomenclature; When Is It Appropriate to Report 99211 During Immunization Administration?. AAP Pediatric Coding Newsletter April 2005; 2005 (2): No Pagination Specified. 10.1542/pcco_book014_document002

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Code 99211 should not be reported for every nurse-only vaccine administration patient encounter. Rather, careful consideration needs to be given concerning the significance and medical necessity for such a visit.

When vaccines are given in the pediatric office, questions often arise concerning the reporting of evaluation and management (E/M) services performed during the same visit as the administration of vaccines. The answer always depends on whether the provider performs a medically necessary, significant, separately identifiable E/M service in addition to the immunization administration. If such a service is performed, an E/M code is reported, most likely from the 99201–99215 code family (office or other outpatient service), in addition to the appropriate code for immunization administration ( 90465–90468 or 90471–90474 ) and the code for the vaccine product(s). In these cases, payers may require modifier -25 (significant, separately identifiable E/M service performed by the same physician on the same day of the procedure or other service) to be appended to the E/M code to distinguish it from the actual administration of the vaccine.

The identification of a significant, separately identifiable service for E/M codes usually involves the performance and documentation of the key components (ie, history, physical examination, and medical decision making) or time. However, 99211 is unique among E/M codes in that it has no key component requirements. The Physicians’ Current Procedural Terminology (CPT ® ) descriptor for code 99211 states, “Office or other outpatient visit for the [E/M] 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.” Therefore, how this concept is defined when the E/M code in question is 99211 needs further clarification.

To address this issue, it becomes important to determine the following:

What services are included in the immunization administration codes?

What additional services are required to appropriately report 99211?

What are the documentation requirements for 99211?

The following services are included in the immunization administration CPT codes:

Administrative staff services such as making the appointment, preparing the patient chart, billing for the service, and filing the chart

Clinical staff services such as greeting the patient, taking routine vital signs, obtaining a vaccine history of past reactions and contraindications, presenting a Vaccine Information Statement (VIS) and answering routine vaccine questions, preparing and administering the vaccine with chart documentation, and observing for any immediate reaction

The relative value units of injectable immunization administration codes have been significantly increased for 2005. This accounts for the fact that many of the services that were previously reported separately with code 99211 are now included in the immunization administration codes.

The immunization administration codes are valued on the Medicare physician fee schedule (Resource-Based Relative Value Scale [RBRVS]) as shown in Table 1 .

* CPT , Physicians’ Current Procedural Terminology ; RVUs = relative value units.

† Medicare 2005 conversion factor = $37.8975. Sample conversion: for 90465 , 0.49 RVUs x $37.8975 = $18.57.

‡ The Centers for Medicare and Medicaid Services considers oral/intranasal immunization administration to be “self-administered” and therefore has not published RVUs for these codes. The American Academy of Pediatrics is working to get RVUs published for codes 90467, 90468, 90473 , and 90474.

The E/M service must exceed those services included in the immunization administration codes. In addition, the following 2 principles must be kept in mind:

The service must be medically necessary.

The service must be separate and significant from the immunization administration.

When the provider (usually the nurse) evaluates, manages, and documents the significant and separate complaint(s) or problem(s), the additional reporting of 99211 is justified. In such circumstances, the nurse typically conducts a brief history and record review, along with a physical assessment (eg, indicated vital signs and observations), and provides patient education by helping the family or patient manage the problem encountered. These nursing activities are all directly related to the significant, separate complaint and unrelated to the actual vaccine administration.

All reported E/M codes must meet documentation requirements as outlined in CPT guidelines or the Centers for Medicare and Medicaid Services (CMS) documentation guidelines. For most of the E/M services physicians perform, this means that some designated combination of the key components of history, physical examination, and medical decision making must be met and clearly documented. Alternatively, if more than 50% of the time spent during the E/M service is in counseling or coordinating care, time becomes the key or controlling factor in selecting a code.

Code 99211 is the one E/M service typically provided by the nurse and not the physician. As such, its documentation requirements differ. There are no required key components typical of the physician services noted previously. Furthermore, the typical time published in CPT for 99211 is 5 minutes. The American Academy of Pediatrics (AAP) encourages documenting the date of service and reason for the visit, a brief history of any significant problems evaluated or managed, any examination elements (eg, vital signs, appearance of a rash), a brief assessment and/or plan along with any counseling or patient education done, and signatures of the nurse and supervising physician.

While not required, it may help payers better understand the medical necessity of the nurse E/M service if, when appropriate, it is linked to a different International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code than the one used for the vaccine given. Encounter documentation should be a separate entry from the charting of the vaccine itself (ie, product, lot number, site and method, and VIS date, which usually are all recorded on the immunization history sheet). Each practice should consider developing protocols and progress note templates for vaccine services.

Finally, if the nurse provides the 99211 visit, it is reported under the physician’s name and tax ID number, making it inherently an incident to service. In such situations, it is a service restricted to established patients and requires the supervising physician’s direct supervision , which is defined by the CMS as the physician being physically present in the office suite (not in the patient’s room) and immediately available to provide assistance. Most nurse E/M services are carried out under a protocol of orders developed by the physician for the particular service and should be fully documented in the record. As always, the physician supervising the care should sign the chart entry.

The American Medical Association provided some instruction on reporting 99211 at the time of immunization administration in its October 1999 CPT Assistant. CPT reaffirms the nature of a reportable E/M service as significant and separate from the immunization administration itself.

The CMS also provides some direction for reporting 99211 for visits in which only the nurse sees the patient and gives an injection. The CMS notes that it is not correct to report an E/M service if the nurse services are only related directly to the injection itself. For 2005, the CMS has significantly increased its fee for immunization administration, providing reimbursement for the typical activities of the nurse as listed herein, under immunization administration. While private payers generally will follow the CMS lead in such coding guidance, it should be noted that some do not use Medicare RBRVS; these payers have their own reporting guidelines and payment policies for nurse visits. As in other coding areas, pediatricians may need to query payers when developing office policies on reporting nurse services and be careful to review the explanation of benefits returned from all payers after these claims are processed.

A 7-month-old girl visits your office to be immunized against influenza and is seen only by your nurse. The nurse takes a brief history and learns the infant has a cough without change in appetite, sleep, or activity level. The nurse takes vital signs, assesses that the infant has no contraindications to getting the vaccine, and discusses the management of the respiratory problem with the parent. Additionally, the nurse documents that the patient meets the current guidelines for vaccination and has no contraindications to the immunization per the Centers for Disease Control and Prevention (CDC) guidelines. Next, the nurse reviews the VIS with the parent and obtains consent for the im-munization. The nurse then administers the influenza vaccine.

The encounter would be reported as follows:

An example of written documentation for this 99211 encounter follows (the actual vaccine data with lot number, site or route, and VIS date are recorded on a separate immunization record):

“The patient is here for the influenza vaccine. Parent reports a cough for several days without any fever. Patient is eating well, and there has been no wheezing or rapid breathing. Her temperature is 98.7ºF and respiratory rate is 38 breaths per minute—she appears well. The symptomatic treatment of the cough per protocol was discussed and the parent was instructed to call or return if the problem worsened.

“She has no allergies to foods or history of reactions to past vaccines. The risks and potential side effects of the influenza vaccine were discussed after the VIS was given, and the parent was informed of the correct dosage of an antipyretic should fever or fussiness occur afterwards. An influenza vaccine was given.

“K. Brooks, LPN/R. Dunn, MD (signatures/date)”

A 5-year-old is brought in by a parent for a catch-up measles-mumps-rubella (MMR) vaccine. The parent says the child is fine and has already been counseled on the vaccine and has no concerns. The nurse proceeds to review the vaccine history, present the VIS, and receive an order for the vaccine from the physician. The nurse then administers and documents the vaccine. In this situation, the service is only vaccine related and no significant or separate E/M service is provided. Therefore, the only services reported are the immunization administration and vaccine product codes.

A 4-month-old patient had an illness with high fever at her preventive medicine visit 2 weeks ago, and now returns to see your nurse for her second hepatitis B vaccine. The nurse performs an interval history, finding the symptoms from the earlier illness have resolved. The nurse then confirms that the infant is afebrile by taking the infant’s temperature and makes the observation that the infant is playful. After assessing that the patient is currently in good health, the nurse confirms that there are no contraindications to the immunization per CDC guidelines. Next, the nurse reviews the VIS with the parent and antipyretic dosage for weight and gets the parent’s consent for the immunization. The nurse then administers the hepatitis B vaccine, observes for immediate reactions, and schedules the third hepatitis B immunization visit for 2 months later.

This encounter would be reported as follows:

“The patient is here for a missed hepatitis vaccine and has had no fever for 7 days, is eating again, and seems to be well per parent. Past vaccines have been well tolerated. Her temperature now is 98.7ºF and she appears well. The risk and potential side effects of the hepatitis vaccine were discussed after the VIS was given and the parent was informed of the correct dosage of an antipyretic should fever or fussiness occur afterwards. The night call system was explained and the access number given.

Some payers may inappropriately deny claims that link code 99211 to a V ICD-9-CM code. Neither CPT nor ICD-9-CM guidelines prohibit such reporting when the ICD-9-CM code reported is the most specific one available to describe the patient encounter (see Table 2 ). Furthermore, CPT guidelines clearly outline the requirements for reporting a given level of E/M code. If the key components of history, physical examination, and medical decision making or time requirements (when greater than 50% of the visit is spent counseling or coordinating care) are met for a given code, the physician is correct in the reporting of that code. CPT guidelines do not make the reporting of a certain level of E/M code contingent on the patient exhibiting certain symptoms or falling under a particular diagnosis. CPT guidelines correctly recognize that there can be considerable variation in the treatment of a patient with a particular diagnosis and that it is inappropriate to validate the legitimacy of a reported E/M code by the presence of a certain diagnosis(es). Claims adjudication processes that prohibit the reporting of V ICD-9-CM codes with anything other than preventive medicine services CPT codes are inconsistent with CPT and ICD-9-CM guidelines and counterintuitive to the continuum of care that can be provided for a patient with a given diagnosis. It also should be noted that the office or other outpatient services CPT codes (99201–99215) are not limited to sick visits only. Therefore, it is appropriate to report V or any other ICD-9-CM codes that most appropriately reflect the reason for the encounter with the office or other outpatient services codes.

For additional resources and attachments, visit http://www.aap.org/moc/reimburse/codingrbrvsresources.htm . Questions? Please contact the AAP Division of Health Care Finance and Practice at [email protected] .

This document was originally prepared for AAP members on the AAP Member Center Web site ( http://www.aap.org/moc) .

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How to Code for Telehealth, Audio-Only, and Virtual-Digital Visits 

Learn how to accurately get paid for telemedicine services with medical codes for telehealth, audio-only, and virtual-digital visits.

Looking for additional telemedicine coding resources?

Coding for Telehealth Visits

Note:  These tables are informational, not advisory. The AAFP recommends that physicians verify each payer's policy and ask patients to verify their coverage ahead of appointments. 

How do I code a new or established patient telehealth office visit that uses audio-video communications technology?

* Elevance's  policies vary by state; contact your provider-relations representative.

Coding for Audio-only Visits

How do i code an audio-only visit for a new or established patient .

CPT Codes: 99441-99443 

Audio-only scenario notes 

Medicare requires audio-video for most office visit evaluation and management (E/M) services (CPT codes 99202-99215) telehealth services. Audio-only encounters are allowed for certain services. Eligible services may be found on the Medicare Telehealth Services list. Medicare allows audio-only telehealth services for office visit E/M services (CPT codes 99202-99215) for the treatment of mental health conditions.   

UHC states they will consider payment for eligible audio-only services listed in Appendix P of the CPT book. Eligible services must be reported using either POS 02 or 10 and include the -93 modifier. CPT codes billed with modifier -93 that are not in Appendix P will not be considered for payment.   

Private payers vary on covered telehealth services. Check with your provider relations representatives for each payer’s telehealth policy and covered telehealth services. 

CMS will cover telephone evaluation and management (E/M) services (CPT codes 99441-99443) through the end of calendar year 2023. Other services that may be provided via audio-only are available on the Medicare Telehealth List. 

Telephone E/M services are provided to a patient, parent, or guardian and do not originate from a related E/M service within the previous seven days and do not lead to an E/M service or procedure within the next 24 hours or soonest available appointment. 

The following codes may be used by physicians or other qualified health professionals who may report E/M services: 

• 99441: telephone E/M service; 5-10 minutes of medical discussion 
• 99442: telephone E/M service; 11-20 minutes of medical discussion 
• 99443: telephone E/M service, 21-30 minutes of medical discussion 

Telephone E/M services should not be reported when the time spent on the telephone is captured in other services reported, such as: 

• if CPT codes 99421-99423 have been reported by the same physician in the previous seven days for the same problem, 
• when CPT codes 99339-99340 and 99374-99380 are used for the same call, 
• during the same month with CPT codes 99487 and 99489, and 
• when performed during the same service period at CPT codes 99495-99496. 
• Self-funded plans can develop their own policies and may opt out of some cost-sharing waivers. Similarly, Medicaid policies are established at the state-level. The AAFP recommends reaching out to your provider relations representatives or Medicare Administrative Contractors (MACs) to verify policies.  

Coding for Virtual-Digital Visits 

How do i code an e-visit (cpt 99421-99423) for an established patient .

CPT Codes: 99421-99423 

How do I code a virtual check-in (HCPCS codes G2012 and G2010) for an established patient? 

HCPCS Codes: G2012, G2252, G2010 

Virtual/Digital Scenario Notes 

• Patient consent is required and may be obtained either before or at the time of service. 
• Virtual check-ins and e-visits must technically be initiated by a patient; however, physicians and other providers may need to educate beneficiaries on the availability of the service prior to patient initiation. 
• There are no POS or modifier requirements for virtual check-ins or e-visits. Use the POS used for typical services. 

Virtual Check-in (HCPCS Code G2012, G2252) 

• These are brief conversations with a physician or other clinician to determine if an in-person visit is necessary. 
• The communication cannot be related to a medical visit within the previous seven days and cannot lead to medical visit within the next 24 hours (or soonest appointment available). 
• Physician or other clinician may respond to patient by telephone, audio/video, secure text messaging, email, or patient portal. 
• HCPCS code G2010 can be used when a captured video or image (store and forward) is sent to the physician. The physician must follow up with the patient within 24 business hours. The consultation must not originate from an evaluation and management (E/M) service provided within the previous seven days or lead to an E/M service within the next 24 hours (or soonest available appointment). 

E-Visits (online digital evaluation and management services) 

• These are non-face-to-face, patient-initiated communications with the physician through an online patient portal. The communications can occur over a seven-day period, and the exchange must be stored permanently. 
• Cumulative time includes review of the initial inquiry, review of patient records pertinent to the assessment of the patient’s problem, personal interaction with clinical staff focused on the patient’s problem, development of management plans (including generation of prescriptions or ordering of tests), and subsequent communication with the patient. Communication can occur through online, telephone, email, or other digitally supported communication 

Physicians and other clinicians who may independently bill Medicare for E/M services can use the following codes:

• 99421: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes 
• 99422: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes 
• 99423: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes 

E-visits should not be billed on the same day the physician reports an office visit E/M service (CPT codes 99202-99205 and 99211-99215) for the same patient. Additionally, e-visits should not be billed when using the following codes for the same communication: 

• 99339-99340 
• 99374-99380 
• 99487 and 99489 
• 99495-99466 

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