INTRODUCTION

Overview

This topic provides clarification on the appropriate use of CPT code 99211 for clinicians and billing professionals in wound care. 

Background

• Evaluation and management (E/M) CPT® codes were updated in 2021. Since then, providers have been able to select CPT codes 99202-99215 based on the complexity of medical decision making (MDM) or the total time spent on the date of the encounter. CPT® code 99201 (for new patients, level 1) was deleted. However, CPT code 99211 (for established patients, level 1) remains reportable if the physician or other qualified healthcare professional (e.g. physician assistants, nurse practitioners) supervises clinical staff performing the face-to-face services of the encounter. See topic "2021 Office/Outpatient E/M Services Updates for Wound Care and HBOT", 'Quick Reference Tool for Coding of Office/Outpatient E/M Services', and  HCPCS/CPT Codes and Physician Fee Schedule Commonly Utilized in Wound Care and HBOT".
• In January 2022, the American Medical Association (AMA) updated the description of CPT code 99211, by removing the phrase “Usually, the presenting problem(s) are minimal.” This change was made to align the descriptor for CPT 99211 with other office/outpatient evaluation and management (E/M) codes, such as 99202-99215. The update was intended to eliminate confusion regarding what constitutes a minimal problem and to ensure consistency across the E/M codes​.[1] Also, some providers had been incorrectly using 99211 for quick visits with patients, potentially under-serving them. Instead, CPT code 99212, which is intended for straightforward medical decision making, should be the lowest level of service used by a provider in an office or outpatient setting.[2]

Definitions

• CPT code 99211: is described as “Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified healthcare professional”. [3] 
• Immediately Available: CMS has clarified that "immediately available" means "without delay" so Medicare Administrative Contractors consider "immediately available" to mean the supervising physician is in the office suite or patient's home, readily available and without delay, to assist and take over the care as necessary. [4]
• Office Suite: An "office suite" is limited to the dedicated area, or suite, designated by records of ownership, rent or other agreement with the owner, in which the supervising physician or practitioner maintains his/her practice or provides his/her services as part of a multi-specialty clinic. [4] 
• Direct supervision: direct supervision means that the physician or other qualified healthcare professional must be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician or other qualified healthcare professional must be present in the room when the procedure is performed (42 CFR 410.32(b)(3)(ii)).[5]

BILLING AND DOCUMENTATION GUIDANCE

Who can report CPT Code 99211

• CPT 99211 is reported when a member of the clinical staff, other than a qualified healthcare professional or physician (e.g. nursing staff, medical assistants, or technicians), performs an E/M service for an established patient as a part of the patient’s plan of care and under the supervision of a qualified healthcare professional or physician.[4] Examples of services include [6]:
• Hypertension or wound checks by a nurse or medical assistant (MA)
• Application of negative pressure wound therapy or compression therapy by trained nurses, licensed vocational nurses (LVNs) and MAs
• While physicians can report CPT code 99211, CPT’s intent with the code is to provide a mechanism to report services rendered by other individuals in the practice (such as nursing staff, medical assistants, technicians, etc).  These staff members must document the visit with the same level of detail as a provider would. [7]  
• Supervision requirements  [4][7]:
• The supervising physician or qualified healthcare professional must be present in the office suite when the service is provided.
• Incidental services should generally be reported under the name and billing number of the supervising physician or qualified healthcare professional in the office suite at the time of the service.

Documentation/billing requirements for CPT Code 99211

• Purpose of CPT Code 99211: CPT code 99211 is used to document an in-person encounter with an established patient where the encounter includes elements of both evaluation and management [6].
• Chief complaint: A chief complaint is required. This is a concise statement describing the reason for the encounter, typically in the patient's own words. Like any problem-oriented E/M service, a note supporting 99211 must include a chief complaint
• Evaluation: When reporting 99211, documentation should include:
• Reason for the visit and the diagnosis
• Vital signs taken by the staff clinician
• Discussions about current medications
• Answers to patient questions
• Reason for the visit and diagnosis
• Any applicable orders or discussions the clinician had with the physician about the patient
• Management: Some form of management is required, although there are no specific key components for 99211. Even for simple services like a blood pressure check, documentation should clearly indicate what was done and why, consistent with the chief complaint.
• Incident-to Requirements: For Medicare and payers following Medicare's incident-to rules, CPT 99211 is often billed as an incident-to service. Incident-to billing allows non-physician clinical staff (e.g. as nurses, technicians and therapists) to bill for a service under the supervising healthcare professional's identifier at their contracted fee schedule rate. The following criteria must be met [4]:
• Direct Supervision: Services must be rendered under the direct supervision of a physician or other qualified healthcare professional, such as a nurse practitioner (NP), clinical nurse specialist (CNS), or, in the case of a physician-directed clinic, a physician assistant (PA). The supervising professional must be present in the office suite and immediately available.
• The services are furnished as an integral, although incidental, part of the physician's, NP's, CNS' or PA’s professional services in the course of the diagnosis or treatment of an injury or illness.
• Billing 'incident to' the physician, the physician must initiate treatment and see the patient at a frequency that reflects his/her active involvement in the patient's case. The claims are then billed under the physician's National Provider Identifier (NPI).
• Billing 'incident to' the NP, CNS or PA, the nonphysician practitioners may initiate treatment and see the patient at a frequency that reflects his/her active involvement in the patient's case. The claims are then billed under the nonphysician practitioner's NPI.
• Example of CPT code 99211 services:
• A nurse performs a simple dressing change to assess and dress open wounds or other injuries. Code 99211 would be appropriate as long as the dressing change wasn’t performed as part of burn treatment (because there are other specific CPT codes that should be used for burns) or routine post-procedure care (because some procedures have a global period during which associated care is considered part of the payment for the procedure). [7]
• If the patient sees a nurse for a dressing change as per the physician’s orders and the patient brings up another condition, the service no longer qualifies as incident to, and you cannot bill 99211. The physician will need to see the patient and bill the appropriate level of E/M.[2]

Billing Tips

• One important change to CPT code 99211 in 2021 involves the use of time for billing. Previously, the code descriptor stated, "Typically, 5 minutes are spent performing or supervising these services." However, for dates of service on or after January 1, 2021, one cannot bill 99211 based solely on time, unlike other office visit codes. While clinical staff can document the amount of time spent in the medical record, this time cannot be used to determine the code level.[2]
• Additionally, services billed under CPT 99211 cannot be upgraded to 99212 or higher due to an increased workload. For instance, whether the patient has one wound dressing or four, the service would still be billed as 99211, provided all other requirements are met. This ensures that the billing reflects the nature of the service rather than the quantity of work performed.
• For inpatient or outpatient hospital services and services to residents in a Part A covered stay in a skilled nursing facility (SNF) the unbundling provision (1862)(a)(14) provides that payment for all services are made to the hospital or SNF by a Medicare intermediary (except for certain professional services personally performed by physicians and other allied health professionals). [4] 
  
• To ensure compliance, organizations are encouraged to perform a few 99211 audits and make sure to update any templates being used to ensure compliance with the new 2021 guidelines, and to educate both clinical and billing staff on proper documentation.[2]