CPT Code 99211 for an Office Visit

The requirements for most evaluation and management codes have become more accurate over the past few years. However, one prominent exception to this is CPT’s level-I established patient encounter CPT Code 99211 for an office visit. CPT defines this code as an “office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician.” It further states that the presenting problems are usually minimal, and typically five minutes are spent performing or supervising these services. Yet many physicians still confuse with when or why to report this code. This article describes how appropriately reporting 99211 can improve revenue and documentation, and provides specific guidelines and examples that can help physicians identify appropriate uses for the code.

Basic Guidelines for CPT Code 99211

The following guidelines can help you decide whether a service qualifies for 99211:

• The provider-patient encounter must be face-to-face. For this reason, telephone calls with patients do not meet the requirements for reporting 99211
• The patient must be established. According to CPT, an established patient is one who has received professional services from the physician or another physician of the same specialty in the same group practice within the past three years. Code 99211 cannot be reported for services provided to patients who are new to the physician
• An E/M service must be provided. Generally, this means that the patient’s history is reviewed, a limited physical assessment is performed or some degree of decision making occurs. If a clinical need cannot be substantiated, 99211 should not be reported. For example, 99211 would not be appropriate when a patient comes into the office just to pick up a routine prescription

The service must be separate from other services performed on the same day.

Services that are considered part of another E/M service provided on the same day should not be reported with code 99211. For example, if a nurse provides instructions following a physician’s minor procedure or takes a patient’s vital signs prior to an encounter with the physician, 99211 should not be reported for these activities because they are considered part of the E/M service already being provided by the physician.

New Prolonged Services CPT Code

A new prolonged services code (with or without direct patient contact) has been created to describe a prolonged office and outpatient E&M service of 15 minutes beyond the total time of the primary E&M procedure. It can only be reported when the E&M service has been selected based on time alone (not medical decision making) & only after the total time of a level 5 service (either 99205 or 99215) has been exceeded.