HEALTHCARE NAVIGATOR

What’s In Your Back Pocket?

The 99211 coding conundrum and what you can do about it

the unwise and miserly man pinches a penny while a $100 bill flies out of his back pocket. How many times have patients been seen in your office by technicians for follow-up services, to re-refract, review medications or pressures, perform additional testing, or to discuss medications or issues they’re having with their vision? Depending on your size and patient flow, it could be six to 10 times a week!

BILL FOR SERVICES

So, when a patient presents for a follow-up service handled by your trained technical staff, and those services are documented, why not get paid for it? Instead, the technician will often bill for any repeat fields, but not his or her services.

Current Procedural Terminology (CPT) allows for this type of visit by creating an established patient evaluation and management service (E/M) that does not require the presence of a physician. Called 99211, it is defined as “an 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 and take five minutes to perform or supervise these services.

In 2014, this procedure code has been assigned a relative value of 0.56, which roughly translates to about $20 on average for this service. If patients come in for these types of visits, even five times a week, you are losing about $100 a week or $5,200 a year by not documenting or billing for them.

GUIDELINES TO FOLLOW

In order to bill, however, the following guidelines must be met:

Services must meet “Incident-to” guidelines—meaning those that are integral to the doctor’s professional services and are normally provided in the office by an employee­—and require “Direct Supervision,” so the doctor must be present in the office at the time the services are rendered and readily available if needed. In addition:

• DOCUMENTATION. The presenting problem must be documented to show the reason for the E/M service being performed on that date. There must, however, be NO specific history, exam, or medical decision-making elements required to be documented in order to bill for this service.

• MEDICAL RECORD. The record must reflect the reason why services are being done and that they are an integral part of the doctor’s treatment plan, as well as what outcome those services are meant to provide and any follow-up care the patient has been instructed to schedule.

• MODIFIER. When billing for most tests or other ophthalmological services, this E/M code does require the use of a -25 modifier (denoting an additional evaluation and management service was performed on the same date).

A bit confusing, yes, but definitely worth it to catch that $100 dollar bill before it flies out of your back pocket and lands in someone else’s!

— Krystin Keller

Krystin Keller is an instructor and consultant to Cleinman Performance Partners, a business consultancy specializing in the development of high-performance optometry practices. ©2014 Cleinman Performance Partners, Inc.