99211 and Incident To - JF Part B

CPT 99211 is an office or other outpatient visit for the Evaluation and Management (E&M) of an established patient that may not require the presence of a physician. Usually the presenting problem is minimal. Typically, five minutes are spent performing or supervising these services.

Medical records must be adequately documented to reflect the reason for the patient's visit and any treatment rendered. There must be recorded elements of history obtained, examination performed, and/or clinical decision making, as well as physician supervision. Incident to services only apply when there is supervision by a physician.

If the patient is not seen by the physician, all incident to provisions must be met in order for CPT 99211 to be billed. Please refer to Noridian's page on incident to criteria under the Browse by Topic page, Claims and then incident to.

If the sole purpose of a visit to the physician's office is to draw blood or receive an injection, then 99211 should not be billed and only the appropriate injection or blood drawing code should be billed

Conversely, if the patient presents for a prescription refill, blood pressure monitoring, injection, immunotherapy, or anticoagulation monitoring where there is a documented, medically necessary decision by the physician to change or maintain medication dosage, 99211 may be appropriate. In this case the medical record must document that the history and/or exam required a decision and that the physician made the decision, even though the physician does not personally see the patient. CPT 99211 should not be used for routine in person prescription renewals unless the patient's condition requires reevaluation prior to the renewal determination.

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 advice 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 injection is given. History, exam, dosage, and follow up instructions are recorded.
• Office visit for an established patient's periodic methotrexate injection. Lab tests are monitored, signs and symptoms are queried, vital signs are obtained, and injection is given with 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).
• Office visit for an established patient with a new or concerning bruise which is checked by the nurse (whether or not the patient is taking anticoagulants), and 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 having no complaints. Patient is queried by the nurse, vital signs are obtained, patient is observed for bruises and other problems, prothrombin time is obtained, 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, and physician's decision and follow up instructions are recorded.

In each of the above examples, the deciding factor in whether an independent E&M service may be billed is whether the services were provided and documented medically necessary services including clinical history, clinical exam and/or making a clinical decision, and physician supervision.

The following are examples of when CPT 99211 should not be used:

• Office visit for an established patient with Pernicious Anemia who has no complaints and is given a monthly Vitamin B-12 injection.
• Office visit for a normotensive established patient who presents solely to have a routine blood pressure check which is recorded in the chart.
• Office visit for an established patient with a previous stroke who comes to a coagulation clinic staffed by a lab technician or pharmacist. There is no physician in the facility at the time that the blood is drawn. Flow sheet records the date, Prothrombin time, INR, and Coumadin dosage. After results are available, they are sent to the patient's doctor who contacts the patient by phone.
• Office visit for an established patient with long standing allergic rhinitis who receives the monthly maintenance allergy injection. Patient is having no symptoms and the flow sheet lists the date, dilution strength, dosage, and instructions regarding the next injection date.

In each of the above examples some or all of the following items are not present and criteria for 99211 are not met. There is no medical necessity for the visit, no documentation of clinical history, no clinical exam, no clinical decision, and/or no physician supervision.