Here’s why 99211 flashes a bright red ‘audit me’ sign at payers.
At roughly $60 a pop, missing just one 99213 service a day could cost your practice more than $15,000 a year. Use these official rules from Medicare to be sure you know when you should —and shouldn’t — add an E/M code to your therapeutic drug and chemotherapy administration claims.
Nip 99211-Based Denials in the Bud
Medicare will not pay 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) separately when you report it alongside the following:
• Chemotherapy or nonchemotherapy drug administration
• Diagnostic or therapeutic drug injection.
The Medicare Claims Processing Manual (MCPM), Chapter 12, Section 30.6.7.D spells this rule out for you.
The reason Medicare doesn’t reimburse 99211 separately is that CMS included “the work and practice expenses” of 99211 in the fees for administration codes 90760-90775 (renumbered as 96360-96375 on Jan. 1, 2009) and 96401-96425, according to the NCCI Policy Manual for Medicare Services, Chapter 11, Section N.3.
Example: Suppose a patient’s nausea complaint during chemotherapy requires a nurse assessment. The nurse consults the physician to adjust the pre-med order, but the physician doesn’t directly see the patient, proposes Kelly C. Loya, CPC-I, CPhT, senior consultant with Los Angeles-based Sinaiko Healthcare Consulting. This scenario might meet the basic definition of 99211, but you should not report 99211 in addition to the chemo admin code according to Medicare’s rule.
Similarly, patient questions or a therapeutic regimen change might prompt the nurse to provide additional 99211-level education on the administration day. But again you should not report 99211 in addition to the chemo code, Loya says.
Stay Alert for Non-99211 Opportunities
Although you may not report 99211 on the same date as drug and chemotherapy administration codes, the MCPM and CCI manual indicate you may report other non-facility based E/M codes (99201-99205, 99212-99215, Office or other outpatient visit …) if the physician provides a significant and separately identifiable E/M service. The MCPM adds that the E/M service must be medically necessary.
Don’t miss: When the documentation supports reporting an E/M code in addition to an admin code, you should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code, instructs the CCI manual.
ICD-9 tip: The MCPM states that you do not need separate diagnoses for the E/M and admin codes, but many coders say separate documented and reported diagnoses make denials less likely. You still should use modifier 25 if you have two distinct and separate reasons/diagnoses supported by the medical record, says Sharon Knutson-Holmes, CPC-H, CPAT, CCA, a compliance auditor for Springfield Clinic in Illinois.
Example: Suppose a patient with breast cancer presents for chemotherapy, and the oncologist performs an E/M above the 99211 level because the patient complains of nausea and vomiting. Link the encounter code V58.11 (Encounter for antineoplastic chemotherapy) and the malignancy (such as 174.1, Malignant neoplasm of female breast; central portion) to the chemo admin code. Then link the nausea and vomiting (787.01, Nausea with vomiting) to the E/M code and append modifier 25.
Remember: Staff may refer to 99211 as a “nurse” visit, but any qualified auxiliary personnel or even the oncologist could perform this level-one service. Don’t base your code choice solely on who performs the visit — be sure documentation backs up your decision.
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