CPT® 99221 in section is for new or established patient initial hospital inpatient care services. 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.”
Initial hospital care, per day, for the Evaluation & Management of a patient, which requires these 3 key components:
- A detailed or comprehensive history
- A detailed or comprehensive examination
- Medical decision making that is straightforward or of low complexity
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient’s hospital floor or unit.
Who can bill for a 99211?
Under Medicare law, only physicians and specified non-physician practitioners (nurse practitioners, clinical nurse specialists, physician assistants and certified nurse midwives) (“NPPs”) can bill for 99211 and any other E/M services which are medically necessary.
Appropriate Use of CPT Code 99211
Because the appropriate use of CPT code 99211 is often confusing, we offer the following guidelines. The key points to remember regarding CPT Code 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.
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.
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
CPT code 99211 should not be used to bill Medicare in below situations:
- 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.
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