AMA Definition – Minimal Problem
Since 2021, the AMA definition of a “minimal problem” is a problem that may not require the presence of the provider. This type of visit is performed “incident-to” an established care plan and under the direct supervision of the physician or non-physician. Performance or supervision of these services typically takes 5 minutes.
Before 2021, the amount of time spent with the patient could be counted when billing CPT 99211. However, as of 2021, AMA removed the time option for this CPT only and now requires the medical decision to be of minimal complexity.
CPT code 99211 is defined as a minimal, low-level Evaluation and Management (E/M) service, often referred to as a “nurse visit”, and has a CMS national allowable of $23.30 for the 2024 calendar year.
Healthcare providers, such as physicians, nurse practitioners, or physician assistants, typically bill E/M codes for evaluating and managing a patient’s medical condition. To bill for a 99211, the nurse must provide a brief and limited E/M service to a patient, such as taking a patient’s vital signs, giving medication or injections, wound dressing changes (outside of global), blood pressure checks or providing simple patient education. However, they must do so within the scope of their authorized duties and responsibilities, as defined by state regulations and their healthcare organization requirements.
Nurse visits and dressing changes
If the patient sees a nurse for a dressing change as per the physician’s orders and brings up another condition, the service no longer qualifies as incidental, and you cannot bill 99211. The physician will need to see the patient and bill for the correct level of E/M. Additionally, the service must meet the criteria outlined in the CPT code description to be eligible for billing.
Can a Rad Tech bill a 99211 visit?
Since Rad Techs typically only conduct diagnostic imaging procedures, they typically cannot bill for E/M services. They specifically lack the authorization to conduct evaluations or provide patient management that would require an E/M code.
It’s essential to check with your specific healthcare organization, as billing practices can vary depending on local regulations and the scope of practice defined for rad techs. Always ensure compliance with your institution’s policies and relevant regulations when billing for healthcare services.
99211 Must Meet Incident-to-Requirements
If that last bit sounds familiar to you, it’s because of the incident-to-rules. All 99211 services must meet these requirements of incident-to:
- The physician or non-physician practitioner (NPP), such as a nurse practitioner (NP), certified nurse-midwife (CNM), clinical nurse specialist (CNS), or, in a physician-directed clinic, a physician assistant (PA), directly supervises the rendering of the services.
- During the diagnosis or treatment of an injury or illness, the physician or NPP provides these services as an integral, albeit incidental, part of their professional services.
- When billing the incident to the physician, the physician must initiate treatment and see the patient at a frequency that reflects their active involvement in the patient’s case.
- For new problems, the physician must see both new and established patients, and bill the claim under the physician’s National Provider Identifier (NPI).
Follow Local Guidelines
It’s important to note that the specific requirements for billing a 99211 may vary depending on local regulations, insurance policies, and the scope of practice defined for nurses in your area. CPT code 99211 may apply whether the patient sees the physician, a nurse, or a non-physician practitioner (NPP), such as a physician assistant or nurse practitioner. However, visits with physicians and NPPs typically qualify for a higher–level E/M code.
Candice Chandler CPC, CEMC
StreamlineMD Coding Manager
StreamlineMD provides Revenue Cycle Solutions to Radiology & Interventional Specialists. Our Mission is to Improve Healthcare for All Americans. Our Core Values that guide us on our mission are Service Quality, Teamwork, Accountability, Efficiency, Adaptability, Communication, and Integrity. Learn more about us at streamlineMD.com.
