Coding Level-One Office Visits: A Refresher Course - = July/August 2000

From: Subject: Coding Level-One Office Visits: A Refresher Course - July/August 2000 - Family Practice Management Date: Fri, 9 Mar 2007 09:44:30 -0800 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0055_01C7622F.89183B00" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3028 This is a multi-part message in MIME format. ------=_NextPart_000_0055_01C7622F.89183B00 Content-Type: text/html; charset="utf-8" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.aafp.org/fpm/20000700/39codi.html =EF=BB=BF Coding Level-One Office Visits: A Refresher Course - = July/August 2000 - Family Practice Management

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<= /DIV>AAFP Home Page = > News=20 & Publications > Jo= urnals=20 > FPM=20 > July/August=20 2000

July/August 2000 (table = of=20 contents)

Vol. 7, = No. 7

Coding Level-One Office Visits: A Refresher=20 Course

If you're forgetting to bill = 99211 for=20 nursing visits, or using 99201 when you should = be using=20 99202, this quick coding lesson may improve your = practice's bottom line.

James M. Giovino, MD

Covered in = FPM=20 Quiz

SPEEDBAR_=C2=AE =

=C2=BB=20 Using=20 code 99211 to bill for required nursing = visits can=20 be financially advantageous to a medical=20 practice.

=C2=BB=20 Code=20 99201 has more specific requirements than = code=20 99211.

=C2=BB=20 Code=20 99201 should not be used for nursing = visits; a=20 physician visit is = required.

=C2=BB=20 A=20 typical 99201 visit would be an = out-of-town=20 patient needing refills on an=20 = NSAID.

"Level-one" office=20 visits may be the simplest of patient = encounters, but=20 when it comes to coding and documentation, they = are=20 widely misunderstood. More often than not, we = tend to=20 forget to bill 99211 for nursing visits and we = undercode=20 physician visits. One of the key problems, of = course, is=20 that the rules for coding and documentation are = clear as=20 mud, while the threat of audit is clear as day. = The=20 revised revised documentation guidelines, = which=20 are at least a year away from being implemented, = may=20 help the situation. But until then, family = physicians=20 can do better by reacquainting themselves with = the most=20 effective use of level-one evaluation and = management=20 (E/M) office visit codes.

99211

According to the CPT manual, a 99211 is an = office or=20 other outpatient visit "that may not require the = presence of a physician. Usually, the presenting = problem(s) are minimal. Typically, five minutes = are=20 spent performing or supervising these services." = Unlike=20 the rest of the office visit codes, 99211 does = not have=20 any documentation requirements for the history, = physical=20 exam or complexity of medical decision making. = The=20 nature of the presenting problem need be only = "minimal,"=20 such as monthly B-12 injections, suture removal, = dressing changes, allergy injections with = observation by=20 a nurse, and peak flow meter instruction. (For = more=20 examples, see Appendix D of the CPT manual.)

The cost=20 to standardize nursing documentation is = minimal: a=20 few copies of a form per year.=20

None of these visits requires the presence of = a=20 physician in the exam room (although the = physician=20 should be on the premises). In fact, as a rule = of thumb,=20 a physician should not code a 99211. What these = visits=20 do require is supporting documentation, so if = you plan=20 to charge for nurses' visits, you need to train = your=20 nurses to provide very basic medical = documentation. I=20 have found the most successful method for = achieving=20 adequate and consistent documentation from = nurses is to=20 make simple, check-box-driven forms, which guide = nurses'=20 decision making, protect you from litigation and = give=20 you the clinical data you would want yourself. = (For=20 examples of flow sheets that can assist nurses = in=20 documentation, see below.)

KEY = POINTS:=20

Physicians generally should not use = a 99211=20 code for their own services, but it may = be=20 appropriate for office services = performed by a=20 nurse.=20
To support the 99211 code for a = nursing=20 visit, a practice must have sufficient=20 documentation.=20
If physicians use code 99201 = regularly, they=20 are likely undervaluing or = underdocumenting=20 their services. =

If you are not sure it is worth the effort to = bill=20 for a 99211, consider that a nursing visit for a = depo-progesterone shot can generate a charge of=20 approximately $150 (nursing visit 99211=3D$30,=20 Depo-Provera 150 mg J1055=3D$90, urine pregnancy = test=20 81025=3D$38), which even after insurer discounts = is a=20 significant amount. In my office, before we = standardized=20 nursing documentation and billing, we failed to = capture=20 approximately $4,000 per year for various = portions of=20 the nursing visit for depo-progesterone shots = alone. The=20 cost to standardize nursing documentation is = minimal: a=20 few copies of a form per year. The nurses spend = no more=20 time charting and are less confused about what = they=20 should be doing.

One word of caution about 99211: You can't = bill for=20 the administration of an injectable medication = (90782)=20 or for the administration of an immunization = (90471,=20 90472) and a nursing visit at the same time. You = can=20 either bill for the 99211 plus the medications = or bill=20 for the injection plus the medications. When the = nurse=20 must make an evaluation of the patient (e.g., = when=20 giving a depo-progesterone shot, the nurse must=20 consider, "might the patient be pregnant?"), = then our=20 practice uses the 99211. If the nurse must only = give an=20 injection, we use the injection codes.

3DPDF=20 This=20 flow sheet can be downloaded as a = PDF.

Depo-Provera Flow=20 Sheet Name: = __________________________________=20 DOB: _____/_____/_____ = MRN:=20 _________________
Drs. order to give = Depo-Provera=20 150 mg IM q3 mo: ______________________ = MD/DO=20
Date of=20 injection (mm/dd/yyyy)	Injection=20 within 3 months of last injection? (If = "no,"=20 perform UCG.)	UCG=20 results (if indicated)=20 If positive, do not give shot.=20	Billing=20 completed by nurse	Lot #	Nurse's=20 initials
	Yes No	Positive Negative =	99211 (visit) J1055 (depo) 81025 (UCG) =

Documentation help

Nurse charting = for 99211=20 visits can be minimized and made more = efficient by=20 moving it almost entirely to flow sheets, = such as=20 the two shown here. Longer notes, such as = involved=20 phone messages, can be documented in the = progress=20 note section of the chart to avoid filling = up the=20 flow sheet with narrative information. = Nursing=20 data need not be repeated in the progress = note.=20

In the flow sheet for depo-progesterone = injections (above), the idea is, first, to = collect=20 the data needed to protect the patient = from=20 iatrogenic injury; second, to drive = effective=20 billing; and third, to minimize the effort = needed=20 for adequate documentation.

The vital signs = flow sheet=20 (right) not only improves nurses' = documentation=20 but improves physician efficiency as well = by=20 allowing for rapid review of vital signs, = past=20 office visits, routine health care and=20 medications. To inform the physician of a = chief=20 complaint, the nurse can simply attach a = sticky=20 note to the front of the chart. Scan the = sample=20 vital signs flow sheet and see if you can = get a=20 feel for this patient without reading the = progress=20 notes.

Note that, in our practice, we = highlight=20 no-show appointments and = narcotic/benzodiazepine=20 prescriptions in green and yellow, = respectively.=20 We have found that these features alone = make the=20 form worthwhile.

3DPDF=20 This=20 flow sheet can be downloaded as a = PDF.

Vital=20 Signs Flow Sheet=20

Name:=20 __________________________________	Predicted peak flow: = __________
DOB: _____/_____/_____	Height: __________
MRN: _________________	Ideal weight:=20 = __________

Date

Nurse = initials

Wt #

Peak = flow

Diagnosis,=20 meds, notes

Dr. = initials

1/4/00

JBL=20

185

182/98

97.4

Elevated BP

JMG

1/10/00

JBL

188

180/100

96.8

Nurse visit 3DX=20

1/17/00

TRB

186

180/96

98.0

HTN start atenolol 50 mg po qd = #30=20 r1

JMG

2/15/00

KEM

186

176/90

97.6

HTN

atenolol 100 mg = po qd #30=20 r1

JMG

3/10/00

JBL

188

160/80

96.8

HTN add HCTZ 12.5 mg po qd #30 = r1

JMG

3/12/00

JBL

187

154/78

97.6

L shoulder disloc and lac = repair

Tyl#3 2 po q4h=20 prn #30 r0=20

RJK

3/19/00

JBL

188

150/78

97.8

Nurse visit suture removal, L = arm lac=20 healing well, no infection, sutures=20 removed

4/8/00

NO = SHOW #1=20 Letter sent=20

4/12/00

TRB

Nurse visit depo see = flow=20 sheet

4/16/00

KEM

Tel.- Pt wants HTN med = refills, told=20 NTBS first. Apt. scheduled for 4/19/00=20

4/19/00

NO = SHOW #2=20 Letter sent=20

4/26/00

KEM

188

150/74

96.6

Well-woman exam + HTN (mamo = sched.) Add=20 lisinopril 10 mg po qd #30 = r3

JMG

99201

In general, of the "new patient" codes, 99201 = should=20 be used only slightly less frequently than = 99205. The=20 goal is not to game the system and upcode, but = if you=20 find yourself using 99201 regularly, consider = auditing=20 your own billing and documentation practices. = You will=20 most likely find that you are either = undervaluing your=20 services or underdocumenting.

The 99201 code has more specific requirements = than=20 99211 when it comes to elements of the history, = physical=20 and medical decision making. (See=20 the table, on page 41, for the minimum required=20 elements.) In addition, = 99201 is not=20 to be used for nursing visits, as the physician = needs to=20 see the patient and establish a care plan before = nurses'=20 visits can be billed.

99201 quick reference

99201
Key=20 components (need all three)	Elements	Minimum=20 requirements
Problem-focused history	HPI	1
ROS	0
PFSH	0
Problem-focused exam	Body=20 areas/organ systems	1
Straightforward medical = decision=20 making (need at least two)	Diagnoses/management = options	1 point=20 (minimal)
Amount/complexity of = data	0-1 point=20 (minimal or none)
Risk	1=20 (minimal)=20 =

Unlike code = 99211, which=20 has no specific documentation = requirements, code=20 99201 for the evaluation and management of = a new=20 patient requires a problem-focused = history, a=20 problem-focused examination and = straightforward=20 decision making, as outlined in the table = at=20 right.

Examples of typical 99201-type office visits = from the=20 CPT manual include an out-of-town patient = needing=20 refills on an NSAID, a topical preparation or an = antihistamine for allergies. For documentation, = remember=20 to record a chief complaint, one element from = the HPI=20 and one physical exam bullet, and specify a = diagnosis=20 and plan.

Bottom=20 line

When it comes to level-one office visits, = three=20 general rules should keep you on track:

Don't forget to bill for the nurse's time = and=20 expertise by using the 99211 code.=20
Use check-box forms to drive adequate=20 documentation, to achieve consistency between = nurses=20 and to capture all appropriate fees.=20
Consider the use of a 99211 or 99201 for a = physician visit as a red flag = indicating=20 potential undercoding.

If you are=20 tempted to downcode for your poorer = patients,=20 remember that you will be committing = fraud.=20

If you are tempted to downcode for your = poorer=20 patients, remember that you will be committing = fraud by=20 billing one group of patients differently from = another.=20 Medicare gets very upset about this. The best = way to=20 help your patients who are less able to pay is = to use=20 the correct billing codes and documentation but = use=20 financial hardship forms to adjust their bills = or set up=20 reasonable payment schedules.

Proper coding and documentation is crucial to = the=20 success of any medical practice. If you spend a = little=20 time making sure you and your staff understand = level-one=20 visits, you may find that it enhances your = practice's=20 bottom line and protects you from legal trouble. =

Editor's = note:=20 For additional coding assistance, see "The = Pocket Guide=20 to the Documentation Guidelines" in the January = 1998=20 issue of FPM. To order a copy, call the = AAFP=20 order department at 800-944-0000 and ask for = item A-557.=20 Please keep in mind that CPT and ICD-9 codes = change=20 annually. For the most detailed and up-to-date=20 information, refer to the current CPT manual, = the=20 related "Documentation Guidelines for Evaluation = and=20 Management Services" and the ICD-9 manual.

Dr. Giovino is = director of=20 the Mercy Health System Family Practice = Residency=20 Program in Janesville, Wis., and is a = contributing=20 editor to Family Practice=20 Management.

Copyright =C2=A9 2000 by = the American=20 Academy of Family Physicians.
This content = is=20 owned by the AAFP. A person viewing it online = may make=20 one printout of the material and may use that = printout=20 only for his or her personal, non-commercial=20 reference. This material may not otherwise be=20 downloaded, copied, printed, stored, = transmitted or=20 reproduced in any medium, whether now known or = later=20 invented, except as authorized in writing by = the AAFP.=20 Contact fpmserv@aafp.org=20 for copyright questions and/or permission=20 requests.

=20 =

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