Written by Brooke Haycraft, CEMC, CFPC, CPC-H, CPC
CPT code 99211 is defined as 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 and five minutes are typically spent with the patient performing or supervising these services.
Although the definition of 99211 seems fairly uncomplicated, numerous coders and healthcare providers alike still struggle with the concept of billing 99211. Further, applying the accurate guidelines to bill 99211 as ‘incident-to’, for prescription refills, anticoagulation monitoring, injections, and blood pressure monitoring can be tricky.
Per the Center for Medicaid & Medicare Services (CMS), ‘incident-to’ billing is described as services or supplies furnished as an integral but incidental part to physician professional services in the course of diagnosis or treatment of an injury or illness in the physician’s office or in a patient’s home. These services, in turn, are billed under the provider, even if the provider was not necessarily present when the services were performed.
To qualify for reimbursement, there are several requirements of, ‘incident-to’ that must be fulfilled. Examples of these requirements include the following:
- The services/supplies must be performed under the provider’s direct supervision.
- What is the meaning of, ‘direct supervision’? ANSWER: The healthcare provider must be present in the immediate office vicinity and available to provide assistance through the duration of the time the other healthcare employee is providing care to the patient.
- The services/supplies are routinely performed in the provider’s office/clinic.
- The services/supplies are an integral, although incidental, component to the provider’s professional services.
- The services/supplies must be performed by an individual who is considered an employee of the billing provider.
Of course, there are also several conditions that must be met in order to bill the E/M codes, in general, as ‘incident-to’—
- The patient must be established with an established diagnosis.
- The encounter must be face-to-face.
- There must be an established plan of care in place (in relationship to bullet one).
- There must be an E/M service provided.
- The service must be provided in-office.
The following is a good example when CPT code 99211 may be billed ‘incident-to’—
- Established patient with known hypertension presents for a routine blood pressure check to determine if current medications are working appropriately. The nurse records the patient’s blood pressure reading, brief history, current hypertension medications, and charts information and advice relayed to the patient. Meanwhile, the patient’s provider is actively seeing other patients on the same floor.
In this example, all ‘incident-to’ and 99211 guidelines have been met, which constitutes billing of this visit.
This next case illustrates a situation when 99211 ‘incident-to’ billing should not be utilized—
- Established patient presents in the early morning before the arrival of the primary physician for an insulin check to monitor his diabetes which was newly diagnosed the prior evening during an emergency department visit while out of town. The nurse documents the patient’s current prescription medication and scans the medical records from the emergency room into the computer for further review. Later that day, the physician follows-up with the patient in an email message and requests an appointment with the patient later in the week.
Billing 99211 ‘incident-to’ in this example would not be appropriate as the physician is not physically present in the office and available for direct supervision and there is no established plan of care in place for the current medical diagnosis.
Knowing when and how to bill for 99211 ‘incident-to’ can help increase revenue in your practice. Although billing 99211 ‘incident-to’ tends to be minimal reimbursement compared to other levels of service, documenting these visits correctly in accordance with CPT and CMS guidelines will give you the maximum compensation based on accurate reporting.