CPT CODE 99211: Office or Other Outpatient Visit for the Evaluation and Management of an Established Patient, Low Complexity - Chirotouch
October 20, 2023 by ChiroTouch Team Article Coding
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This quick reference guide to CPT code 99211 answers frequently asked questions from our community of chiropractors. You can see the complete library of CPT codes here, courtesy of ChiroTouch, the cloud-based EHR designed specifically for chiropractors. 

About CPT Code 99211: Office or Other Outpatient Visit for the Evaluation and Management of an Established Patient, Low Complexity

CPT code 99211 is used to bill for an office or other outpatient visit for the evaluation and management of an established patient, typically lasting 5-9 minutes. This code is unique as it may not require the presence of a physician or other qualified healthcare professional. It is often used for follow-up visits, medication management, or for situations where a brief face-to-face interaction with the healthcare staff is needed.

This code can be billed independently or in conjunction with other services.

Category or Type of Service

CPT code 99211 falls under the category of Evaluation and Management (E/M) services. It is designated for established patients, meaning the patient has been seen by the provider or a provider in the same specialty within the same practice within the past three years.

Billing Interval

CPT code 99211 is billed per patient encounter. Each instance of a minimal E/M service, as documented by the chiropractor, constitutes a billable unit. Code 99211 is for visits of low complexity, typically from 5-9 minutes. For higher-complexity encounters, use code 99212, 99213, 99214, or 99215.

When Should Chiropractors Use This Code?

Chiropractors should use 99211 when providing a brief check-up or follow-up visit for an established patient, typically lasting 5-9 minutes. This can include reviewing treatment progress, adjusting medication, or brief counseling about lifestyle changes. It’s important that the service rendered requires at least a face-to-face interaction with the patient by a healthcare professional.

When assessing whether to use 99211 or a higher-level code, consider both the time involved and the complexity of the care provided. Complexity is the more important factor.

Situations where use of 99211 may be appropriate include:

  • Quick consultations
  • Brief follow-up appointments
  • Prescription renewals or medication checks
  • Minor health issues or inquiries

This code is suitable for brief assessments, discussions, or follow-ups that don’t require extensive evaluation but still contribute to patient care.

When Should Chiropractors Not Use This Code?

Chiropractors should not use CPT code 99211:

  • For comprehensive evaluations: If a more detailed assessment is performed, it warrants a higher-level E/M code.
  • Routine chiropractic manipulative treatment (CMT) sessions: When E/M services are an integral part of a CMT session, separate billing using 99211 may not be appropriate.

Which Modifiers Can Be Used With CPT Code 99211?

The following modifier codeshare often used with CPT code 99211:

  • Modifier 25: Indicates that the E/M service is significant and separately identifiable from other services performed on the same day.
  • Modifier AT: Used to signify that a service or procedure was performed for an acute or chronic subluxation. This modifier must be used for 99211 encounters billed to Medicare.

NOTE: Modifier 59 should not be used with CPT code 99211 because it requires a separately billable procedure performed on the same day.

Always review and comply with payer-specific guidelines when using modifiers to ensure accurate and compliant billing.

What Are the Billing Guidelines and Documentation Requirements Specific to This Code?

The following billing guidelines and documentation requirements apply to code 99211:

  • Frequency of use: The frequency with which certain billing codes can be used depends on the client’s insurance plan. Verify with each patient’s insurance carrier to confirm specifics around billing frequency limits for this CPT and similar codes prior to submitting claims.
  • Established patient: An established patient-provider relationship must already be in place, as this code does not apply to new patients.
  • Face-to-face encounter: The provider must actually see the patient, either in person or by telehealth. Over-the-phone services do not qualify.
  • Care provided: Some evaluation and management of the established patient must occur during the visit. Simply documenting a patient’s medical history alone is not enough. Providers need to identify a clinical need, render care to address the need, and note decision-making regarding the patient’s treatment plan.
  • Separate billing: If additional medical services are provided on the same day, 99211 must be billed as a separate charge.

What Are Examples of ICD-10-CM Codes Often Used With This Code?

The following ICD-10-CM codes are often used with CPT code 99211:

  • Z00.12: Encounter for routine check-up or examination
  • R10.0: Follow-up examination after other procedures
  • R15.2: Follow-up examination after medication use

These are just a few examples. It’s important to select the most accurate and specific diagnosis code based on the patient’s condition and the clinical documentation.

What Are Common Mistakes Made Specific to CPT code 99211?

Some common mistakes made with this code include:

  • Excessive use: Code 99211 is not meant for every service your practice provides. Only use it for established patient E/M visits with minimal problems and minimal chiropractor involvement.
  • Insufficient documentation: Clearly document the history, examination, and medical decision-making performed by the provider. Lack of sufficient detail can lead to denials or audits. Be specific about the minimal problems addressed and how they were managed.
  • Billing for services not included: Don’t bill for phone calls, administrative tasks, or services bundled into other codes.
  • Misusing time-based criteria: While time-based criteria can be a reference point for 99211, it’s not the sole one. Focus on the complexity of the E/M elements (history, exam, MDM) rather than just time. Consider higher-level codes if the encounter involves more complex problems or decision-making, even if it falls within the 5- to 9-minute range.
  • Incorrect use with specific payers: Some payers have specific policies regarding 99211. Be aware of any restrictions or requirements in your region or for your patients’ insurance.
  • Billing for encounters that involved no direct patient contact: Phone calls do not qualify.
  • Using 99211 for a new patient visit. This code is to be used for established patients only.

To ensure accurate billing and minimize claim denials, it is crucial to provide thorough and detailed documentation that supports the medical necessity of the service rendered.

What Are Potential Audit Triggers Specific to This CPT Code?

Some potential audit triggers specific to CPT code 99211 include:

  • Inconsistent use of time: Billing 99211 consistently for all established patient visits, regardless of complexity, raises suspicion. Auditors may scrutinize cases where the documented time aligns perfectly with the 10-19 minute range for the code.
  • Lack of supporting documentation: Vague or incomplete documentation of the history, examination, and medical decision-making (MDM) can raise doubts about the level of service provided. Auditors need clear evidence to justify the code.
  • Inadequate MDM complexity: If the documented MDM is superficial or lacks complexity (e.g., minimal data reviewed, straightforward decisions made), it might not support a 99211 code. Auditors expect a higher level of clinical reasoning for this code.
  • Billing for bundled services: Including services already bundled into 99211 (e.g., simple injections, medication refills) inflates the claim and can trigger an audit.
  • Frequent use for chronic conditions: While 99211 can be appropriate for managing stable chronic conditions, excessive use without evidence of monitoring or adjustments could raise suspicion. Auditors expect proactive management for chronic cases.

What Can I Do to Improve the Accuracy and Efficiency of My Practice’s Billing and Coding Processes?

Improving the accuracy and efficiency of your practice’s billing and coding can be achieved by steps such as:

  • Regularly scheduled auditing of your practice’s billing and coding practices
  • Staying current on any changes to billing and coding regulations
  • Using a cloud-based EHR and practice management software built for the needs of chiropractors

ChiroTouch can help you with billing and coding accuracy. Whatever your preferred payment method or the size of your practice, ChiroTouch can help your team achieve more efficient billing processes, streamline claims management, and free up time for other work.

Contact us to learn more about how to power your practice with ChiroTouch.

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