Coding Cues: Answers to your questions about...

October 5, 2007

Using 99211; modifier -62; newborn care

Key Points

Using 99211

We submit 99211 (office or other outpatient visit for the E&M of an established patient, that may or may not require the presence of a physician . . . ) each time a patient comes in and none of the physicians are in the office. We assume that's okay because the use of 99211 doesn't require a doctor's presence. The patient may come in for a blood pressure check, an injection, or a protime check, and our nurses render the services. Some of my colleagues have told me this is improper billing. Can you clarify the rules?

There are important points to remember when billing a 99211 visit.

You can't use an E&M code unless a separately identifiable service has been rendered to the patient and documented in the record. The visit must be medically necessary. A blanket policy to bill a 99211 with every patient encounter is inappropriate and may lead to an audit of your claims.

Remember that if another CPT code more accurately describes the service the nurse provides, that code should be reported, not 99211. And you shouldn't report 99211 when a patient is seen simply for an injection or blood draw; the nurse's services are included in the procedure charge. On the other hand, it would be appropriate, for example, to submit 99211 when a patient on anticoagulants who has a sudden onset of bruising comes in and sees your nurse. Remember, though, that you or one of your partners should review the supporting history, exam, and counseling the nurse documents in the medical record.

Modifier –62

I frequently perform surgeries along with another surgeon, but I find that my claims are denied even when I use modifier –62 (two surgeons). What else should I be doing besides attaching the modifier?

Both you and the other doctor have to submit your own claims for the same procedures and both must use modifier –62. In addition, the diagnosis codes linked to the procedures must be the same on each claim. You may want your billing staff to coordinate your claims submission and documentation with the other surgeon's office.

Newborn care

Our large pediatric practice routinely sees newborns over several days in the hospital when the mother has to stay extra days. But insurers won't pay for anything other than the first day of care and our discharge service. Is there anything we can do to get paid more?

Probably not. Typically, hospitals require daily visits for an infant, even if the baby is healthy. Unfortunately, most insurers will only pay for the initial evaluation and discharge. And many insurance contracts won't allow doctors to bill the patient's family for the extra days' services. As a result, many pediatricians are petitioning their hospitals to have their hospitalists see healthy newborns when the babies stay longer.

The author, vice president of operations for Reed Medical Systems in Monroe, MI, has more than 30 years' experience as a practice management consultant, as well as being a certified coding specialist, certified compliance officer, and a certified medical assistant.