Nursing Visits in the Office: Navigating Risks and Staying Compliant

Nursing Visits in the Office: Navigating Risks and Staying Compliant

Written by: Sonda Kunzi

Let’s talk about nursing visits. If you have worked in a medical office, you’ve likely heard this term used to describe brief patient encounters with a medical assistant, nurse, or other clinical staff. Things like blood pressure checks, vaccine administration, suture removal, or routine follow-ups often fall under this umbrella. But here’s the challenge: while nursing visits may seem straightforward, there’s a significant gray area when it comes to billing, documentation, and compliance. Misusing this term, or not fully understanding its implications can create compliance risks for the office.

Let’s Start With Defining “Nursing Visit”

A nursing visit typically refers to a clinical staff member, such as a registered nurse (RN), licensed practical nurse (LPN), or medical assistant, seeing a patient without the direct presence (in the exam room) of a physician or advanced practice provider (APP). Common examples include:

• Administering an injection or vaccine (specific CPT codes will apply for this example)
• Performing a wound dressing change
• Checking vital signs or following up on a treatment plan

While these tasks enhance efficiency in patient care, the interpretation of a nursing visit depends on several factors: the nature of the service, the qualifications of the person performing it, and the applicable regulatory requirements.

Common Compliance Pitfalls

1. Billing Assumptions

Not all services performed by nursing staff can be billed as a nursing visit under a provider’s name. Some may qualify under Medicare’s “incident to” billing rules, but others may not. Consider these scenarios:

• If the service is part of a provider-established treatment plan and performed under direct supervision, it may qualify for billing, though scope of practice must still be considered.
• If a new condition arises or the service requires clinical judgment beyond the staff member’s scope, it does not meet “incident to” requirements and may not be billable.

2. Scope of Practice Variations

The legal scope of practice for nurses and medical assistants varies by state. Some states impose strict limitations on what tasks require a licensed professional versus what can be delegated.

For example:

• Medical assistants typically handle administrative and basic clinical tasks (e.g., vital signs, patient prep) but cannot assess or treat patients independently.
• RNs have broader authority but are still bound by state-specific practice laws regarding independent decision-making and their scope in the office may differ greatly from what we see in hospitals.

3. Supervision Requirements

Medicare requires direct supervision for any service billed as “incident to” a provider. This means the supervising provider must be physically present in the office suite and immediately available, not just reachable by phone.

Private insurers may have their own rules, which can be more or less restrictive than Medicare’s. However, Medicare’s standard is generally a good baseline to start. If the provider is not physically present, the service should not be billed as “incident to.”

State Scope of Practice: A Critical Factor

State regulations dictate what tasks RNs, LPNs, and medical assistants can perform. Here’s how different states handle nursing scope of practice:

• Ohio: RNs can assess and educate patients independently, but LPNs require provider or RN oversight. Medical assistants are limited to basic delegated tasks. https://www.ossma.org/scope-of-practice
• California: Medical assistants may administer injections, but only under on-site provider supervision. https://www.mbc.ca.gov/FAQs/?cat=Licensees&topic=Medical%20Assistants
• New York: Medical assistants may conduct patient intakes, collect and prepare lab specimens and administer EKGs. https://nyhealthfoundation.org/resource/medical-assistants-in-new-york-state/

Failing to comply with state-specific regulations can lead to licensing issues, reimbursement denials, or even legal consequences.

The Importance of Proper Documentation

Auditors will rely on documentation, and vague chart notes are a red flag. Simply documenting “nursing visit for BP check” is insufficient. Instead, documentation should include:

1. A direct connection to the provider’s treatment plan
2. A clear description of the service provided and its medical necessity
3. Evidence of supervision (as required, for example flu and COVID vaccines may be administered without direct supervision if allowed by scope of practice)

If it’s not documented, there is no proof to defend the requirement of a service was met, a rule every practice should follow.

Best Practices for Compliant Nursing Services

Here are 5 steps to successfully managing nursing visits:

1. Establish a Clear Definition

Define what your practice considers a nursing visit and outline which services can be performed by RNs, LPNs, or medical assistants. Ensure all staff understand their role limitations.

2. Align Tasks with Scope of Practice

Verify that state regulations align with your protocols:

• RNs may handle assessments and patient education.
• LPNs may perform treatments under provider oversight.

• Medical assistants should be limited to supportive clinical tasks within their scope, such as taking vitals, preparing patients for exams, and administering injections under direct supervision when allowed by state regulations.

3. Ensure Proper Supervision

If billing under “incident to” guidelines, confirm that a provider is physically present in the office. Available by phone does not meet Medicare’s direct supervision requirements.

4. Train Staff Regularly

Ongoing education ensures compliance. Training topics could include:

• Scope of practice regulations
• Documentation requirements
• When to escalate patient concerns to a provider

5. Conduct Proactive Audits

Regular audits of billing based on rendering provider (a term used to identify who actually performs the service, billing provider would indicate how the claim was submitted) can help identify potential compliance gaps before they become liabilities. Since 99211 is a typical code used, a report of billed services can be run for part of the validation audit.

Final Thoughts

Nursing visits can improve practice efficiency and often increase revenue as well, but they require careful adherence to federal and state regulations. By clearly defining responsibilities, maintaining proper supervision, and ensuring accurate documentation, practices can avoid compliance pitfalls while still delivering good quality care.

Compliance isn’t just about avoiding penalties—it’s about protecting patients, staff, and an organization’s reputation.

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Take Action Today

Take charge of your practice’s compliance today! Review your current nursing visit protocols, update your documentation practices, and ensure your staff is fully trained on the latest federal and state guidelines. Don’t wait for a compliance issue to arise—proactively safeguard your practice’s reputation, revenue, and patient care quality. Contact us now for a comprehensive consultation and audit to transform your nursing visits into models of efficiency and regulatory excellence. Contact Us Now to review your nurse visits or understand better how to use this service category.

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About the Author:

Sonda Kunzi, CPC COC CPB CRC CPCO CPMA CPPM CPC-I

With more than 35 years of experience, Sonda earned a reputation as an expert in healthcare coding, compliance, and reimbursement strategies. She specializes in behavioral health and functional medicine helping simplify complex topics for providers.