We frequently receive questions regarding the infamous “nurse visit,” and what documentation Medicare or other payers expect to see when billing the Current Procedural Terminology code 99211. So, what are the exact medical documentations that would support billing the evaluation and management (E&M) code 99211 alone or with other billable services?
Although the presenting problem is usually minimal, with 5 minutes generally spent providing the service, there must be a presenting problem or chief complaint documented, demonstrating the reason for an E&M service on that particular date of service.
In addition, the medical record should indicate the nature of the E&M service that occurred on the date being billed, and show that the service was an integral, although incidental, part of the physician’s previous professional service.
Here is an example regarding the documentation that should support billing code 99211:
A patient comes in to learn how to self-inject a prescribed medication. The medical record should demonstrate that the medication is part of the patient’s plan of care, and that during a previous visit or phone call, the physician told the patient to come into the office so that the nurse could go over the medication and its side effects with the patient, and demonstrate how to self-administer the injection. The nurse’s notes should reflect exactly what transpired at his or her encounter with the patient.
Do not bill a code 99211 when the nurse administers an injectable medication—the relative value units for 99211 are included in the administration code, making 99211 not billable. In addition, all of the incident-to criteria noted above must be met.