CPT 99211

CPT 99211 – Inappropriate Usage (2021)

CPT 99211 describes a service that is a face to face encounter with a patient consisting of elements of both evaluation AND management.  The evaluation portion of 99211 is substantiated when the record includes documentation of a clinically relevant and necessary exchange of information (historical information and/or physical data) between the provider and the patient. The management portion of 99211 is substantiated when the record demonstrates an influence on patient care (medical decision-making, provision of patient education, etc.).

Inappropriate Usage of CPT 99211

CPT 99211 is not to be used:

To bill Medicare for phone calls to patients.

To bill Medicare solely for the writing of prescriptions (new or refill) when no other evaluation and management is necessary or performed.

To bill Medicare for blood pressure checks when the information obtained does not lead to management of a condition or illness.

To bill Medicare when drawing blood for laboratory analysis or when performing other diagnostic tests whether or not a venipuncture or other diagnostic study test is submitted separately.

To bill Medicare when drawing blood for laboratory analysis for anti-coagulation monitoring and no face to face counseling occurs with the beneficiary, even if a results later that day are called to the beneficiary.

To bill Medicare for face to face counseling that is provided without a medical need for such counseling; i.e., provided solely because the patient comes for laboratory testing.

To bill Medicare routinely when administering medications whether or not an injection (or infusion) code is submitted separately.

Reference: https://www.novitas-solutions.com/bulletins/parta/archive/mpr03145.html

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