Do you often bill the code 99211? I must admit, this is a service code that isn’t used much anymore, but it can be an excellent code to bill for the overhead when using our office staff.
Let’s start with the Par Agreement entered into with your chosen insurance providers. This agreement states that claims be submitted for any billable and reimbursable services provided to patients. Therefore, you should be billing for those nurse visits.
So then, why have we seen a decline in nurse utilization visit codes? There may be several reasons for this decline, such as high deductible health plans; a lot of patients push back and think they should not have a copay or a high deductible premium just to visit the clinical staff. Something that I have repeated throughout my career is, “If you can be sued for it, then you certainly have the opportunity to bill for that service.” As an example, let’s say a patient is seen for a blood pressure check, and something goes catastrophically wrong after that blood pressure check based on a poor reading by staff. Then certainly you should be able to be reimbursed for that service. We absolutely should be looking at those services as ones that we bill for and are reimbursed for. Providers in a lot of practices have instructed their staff to stop billing for it because they’re tired of dealing with the pushback from patients. But again, our Par Agreement states that if a patient is being seen for a service, the insurance company should be billed for that service. Therefore, you should bill that service.
The inspiration for this topic came from a NAMAS member that asked, “Is it appropriate to bill for a nurse visit when a patient comes to the office to review the instructions for a home sleep test?”
So, if I’m telling you to bill for nurse visits when we can, and your insurance companies say that you should, I should then follow that up by telling you when it is appropriate to bill for these visits. The best rule of thumb is like anything else in our industry: when it’s medically reasonable and appropriate. Is it medically reasonable and appropriate to have that interaction with the patient? If the answer is yes, then it could be reimbursable if and when documented appropriately.
I will answer the original question in just a moment, but first, let’s look at another example that is kind of grey.
A patient goes into the office to get medication samples. Just to pick up samples. They go to the front desk and pick up samples and leave. Absolutely not; this is not a billable service. However, if a patient goes into the office to pick up medication samples for birth control because they can’t get in to see the OBGYN for another month, and the medical assistant takes them back and asks questions like, “Are you smoking? Have you had regular menstrual periods? What’s been going on?” They are doing that small nursing interaction to make sure it’s OK to give the patient that sample. Yes! That could be a medically appropriate encounter.
Let’s take it a step further.
Frequently, patients need to visit the office for a second urine check. The medical assistant, the lab tech, the nurse, or whoever is looking at it reports to the patient that the urine is clear and asks how they are symptomatically. Second urine checks? Absolutely. Now, if they are just dipping the urine and not performing an engaging follow-up, just doing a urinalysis, that’s not a reimbursable encounter. The key here is that it’s just like a physician visit. Are you doing a follow-up nurse assessment with that patient or just a urinalysis?
So, our NAMAS member’s question states that they are giving a patient instructions for a home sleep test. Now, if our member were here sitting beside me, I would ask, “Well, are you going to bill for that home sleep study?” Because that is work that you’re doing. You’re doing work toward that “pre-op” (if you want to call it that). It’s work towards prepping that patient and getting them ready for that home-based study. So no, that’s not a billable nurse visit because you’re giving them the equipment to do a study that should then be billed in the practice. Be careful what lines you’re crossing.
Another question that comes up a lot is who can perform a nurse visit. It does not have to be an RN, an LPN, or a medical assistant. It can be anyone whom the physician, NP, or PA that they are billing under deems appropriate and believes they have the expertise to do that visit. So, those credentials are all that’s required, which may mean no credentials at all. What documentation is required? Enough to substantiate that a medically necessary interaction was provided to that patient during the encounter.
I hope this answers all of your questions about nurse visits and billing 99211. Remember, if you have any questions like this one… that’s why we have the “Ask the Expert” benefit through the NAMAS membership!
Your next steps:
- Become a NAMAS Member to earn those CEUs and take advantage of “Ask the Auditor,” NAMAS learning resources, products, and more!
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Watch Shannon discuss this topic on the NAMAS YouTube channel and subscribe to get notified when new auditing and documentation tips drop!
- Check out the agenda for the 15th Annual NAMAS Auditing & Compliance Conference and register to attend!
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