Coding and Documenting Short, No-Doctor Visits in Urgent Care

Not sure how to code a 5-minute visit from an established patient? Here’s the answer: 99211 (when appropriate)

Code 99211 is defined as follows:

“Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services.”

This is a low-level Evaluation and Management (E/M) service. The patient must have a face-to-face encounter with a staff member in the clinic, but a face-to-face encounter with the doctor is not necessary. Although it may be an ancillary staff member who actually executes the services, the visit may be billed as though the physician personally performed the services if (and only if) the services qualify as “incident-to.” To comply with billing and payment incident-to requirements, documentation must show either a link back to a previous visit with the physician (e.g., “Patient is seen on follow-up as directed by Dr. Smith”) or involvement of the physician directly in the visit (e.g., “History reviewed with Dr. Smith, who concurs”).

When to Use & How to Document
Generally, visits to ancillary staff that involve an element of both evaluation and management qualify for 99211. Unlike with other E/M services, the Centers for Medicare and Medicaid Services (CMS) have left the documentation requirements for this code rather vague. CMS has not quantified specific levels of history, physical exam, and complexity of medical decision making needed. This should not, however, be misunderstood to mean that no documentation requirements exist for 99211; there are, in fact, several. The visit record must show documentation that incident-to services were provided, as defined above. The record must document clinically relevant and necessary exchange of information (historical information and/or physical exam data) between provider (and/or ancillary staff) and patient. Documentation should also demonstrate an influence on patient care (medical decision-making, provision of patient education, etc.). Documentation must be legible and must include the identity and credentials of the individual who provided the service in order to substantiate the code 99211.

Here are a few examples of visits that would meet the requirements for 99211:
Blood pressure check; chart should include:

• the identity and credentials of the staffer(s) providing services
• a clinical reason for checking blood pressure (e.g., “essential hypertension”)
• blood pressure and other vital signs
• current medications listed (with level of compliance noted)

Recheck for an abscess that has improved continuously over several days but requires repeated antibiotic injection treatments; chart should include:

• the identity and credentials of the staffer(s) providing services
• the clinical reason for recheck (e.g., “recheck absess”)
• vital signs
• history of pain, fever, or other symptoms
• physical findings of redness, warmth, swelling, etc.
• injection of antibiotic including drug name, lot number, and location of injection

Recheck for refilling a prescription; chart should include:

• the identity and credentials of the staffer(s) providing services
• a clinical reason for recheck
• vital signs (especially if related to the reason for recheck)
• history of symptoms or their absence since previous visit
• current medications and compliance with taking the medications