This article will define CPT Code 99211, explain the medical necessity to report CPT 99211, the guidelines and clinical examples of CPT 99211.
CPT Code 99211 Description
CPT Code 99211 is defined by the CPT manual as follows (the text in Italic is the official definition of CPT 99211):
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 care professional. Usually, the presenting problem(s) are minimal.
Typically, 5 minutes are spent performing or supervising these services.
Billing Instructions: Bill 1 unit per visit.
CPT 99211 Coding Guidelines
CPT code 99211 is described as a face-to-face meeting with a patient consisting of both assessment elements (requiring documentation of a necessary and clinically relevant data exchange) and management (providing patient care that influences the process decision making or education of the patient). The documentation must be legible and comprise of the identity and credentials of the service provider.
When CPT 99211 is billed as an ‘incident to’ service, the doctor’s service can be performed by ancillary personnel and billed as if the doctor had given the service. The documentation must contain the identity and credentials of the attending physician and of the staff who provided the service. The notes should indicate the degree of involvement of the physician and document the connection between the services of the two providers.
All CPT code 99211 services of which do not document or prove that an evaluation and management service was given and was required will be denied after review.
CPT Code 99211 Examples
Office visit for an 82-year-old female, established patient for a monthly B12 injection with documented Vitamin B12 deficiency. (Geriatrics/Internal Medicine/Family Medicine)
Office visit for a 50-year-old male, established patient, for removal of uncomplicated facial sutures. (Plastic Surgery)
Office visit for an established patient who lost prescription for lichen planus, Returned for new copy. (Dermatology)
Office visit for an established patient undergoing orthodontics who complains of a wire that is irritating his/her cheek and asks you to check it. (Oral & Maxillofacial Surgery)
Office visit for a 50-year-old female, established patient, seen for her gold injection by the nurse. (Rheumatology)
Office visit for a 73-year-old female, established patient, with pernicious anemia for weekly B12 injection. (Gastroenterology)
Office visit for an established patient for dressing change on a skin biopsy. (Dermatology)
Office visit for a 19-year-old female, established patient, for removal of sutures from a 2 cm laceration of forehead, which you placed four days ago in ER. (Plastic Surgery)
Office visit of a 20-year-old female, established patient, who receives an allergy vaccine injection and is observed for a reaction by the nurse. (Otolaryngology/Head & Neck Surgery)
Office visit for a 45-year-old male, established patient, with chronic renal failure for the administration of erythropoietin. (Nephrology)
Office visit for an established patient, a Peace Corps enlistee, who requests documentation that third molars have been removed. (Oral & Maxillofacial Surgery)
Office visit for a 69-year-old female, established patient, for partial removal of antibiotic gauze from an infected wound site. (Plastic Surgery)
Office visit for a 9-year-old, established patient, successfully treated for impetigo, release to return to school. (Dermatology/Pediatrics)
Office visit for an established patient requesting a return-to-weak certificate for resolving contact dermatitis. (Dermatology)
Office visit for an established patient who is performing glucose monitoring and wants to check accuracy of machine with lab blood glucose by technician who checks accuracy and function of patient machine. (Endocrinology)
Follow-up office visit for a 65-year-old female with a chronic indwelling percutaneous nephrostomy catheter seen for routine pericatheter skin care and dressing change. (Interventional Radiology)
Outpatient visit with 19-year-old male, established patient, for supervised drug screen. (Addiction Medicine)
Office visit with 12-year-old male, established patient, for cursory check of hematoma one day after venipuncture. (Internal Medicine)
Office visit with 31-year-old female, established patient, for return to work certificate. (Anaesthesiology)
Office visit for a 42-year-old, established patient, to read tuberculin test results. (Allergy & Immunology)
Office visit for 14-year-old, established patient, to re-dress an abrasion. (Orthopaedic Surgery)
Office visit for a 45-year-old female, established patient, for a blood pressure check. (Obstetrics & Gynaecology)
Office visit for a 23-year-old, established patient, for instruction in use of peak flow meter. (Allergy & Immunology)
Office visit for prescription refill for a 35-year-old female, established patient, with schizophrenia who is stable but has run out of neuroleptic and is scheduled to be seen in a week. (Psychiatry)