99211 “Incident To” Medical Billing Summary
If you reference the CPT Code Book, it would describe a 99211 Evaluation & Management (E/M) code as follows:
An 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 health professional. Presenting problems are minimal. Typically, no more than 5 minutes are spent performing or supervising the services.
Seems simple, but this is the most misused and misunderstood E/M code of all. The following is meant to be used as a resource for creating a process and protocol for services provided by a RN that are “Incident To” a medical provider.
- “Incident to” services are provided by a non-physician practitioner (e.g., RN) and must be billed out under the supervising physician or qualified health care professional who is in the office at the time of service.
- The patient must be established in order to bill a 99211 E/M.
- The patient encounter must be face-to-face.
- An evaluation and management service must be provided.
- The service must be separate from other services performed on the same day.
- The presence of a physician or other qualified health care professional (e.g, CNP or PA) is not required in the exam room, however, all services must be billed under the supervising provider’s NPI number.
- Services requiring DIRECT supervision require that the supervising provider be present in the office suite or building at the time services are provided. The supervising provider does not need to be present in the office suite if only general supervision is required.
- Specific standing orders should be developed for each service the RN would be providing and they must be signed by the program’s medical director. Services delegated must be within a RN’s scope of practice.
- The RN would only be providing services that are included in the standing orders or the patient’s plan of care. The services provided can be billed with 99211 if the services and corresponding document meet the criteria for this and may also include additional CPT codes.
The following are just a few examples for services provided by a RN:
|Service(s) Provided by RN||Does Medical Provider have to be present in the office?||Should service be billed as 99211?|
|No||No. Bill only for the blood draw|
|Yes||Yes. Bill 99211 and the venipuncture. A modifier 25 must be amended to the 99211 showing a separately necessary service was provided.|
|Immunizations||No||No. Only the administration of the vaccine and the biologic is billable. CPT code 99211 is not separately reportable with vaccine administration per the National Corrective Coding Initiative.|
Documentation should include:
- Sufficient information to support the reason for the encounter and E/M service.
- Any relevant history
- Physical assessment and plan of care.
- Date of Service
- The identity of the person providing care.
- Any interaction with the supervising physician or other health care professional.
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Your SCHA-MI Billing Team,