What is a 99211 for E and M coding?

For a physician, nurse practitioner or physician assistant to be compensated for the services they provide to a patient they must correctly document the events that occurred in the room.  However, for the level of service of an established patient 99211, this does change. Unlike all other levels of service, the 99211 can be billed by RNs, LPNs or other non-physician staff. What also sets this code apart is the fact that there are no key components that must be met to fulfill this level of service. 

The E and M code 99211 is the specific code for an established patient Level 1 patient and is used less often than higher codes such as 99213 and 99214. However, this level of service is often overlooked and should most likely be used more often in settings such as family practice and internal medicine.  Simple things like Blood pressure rechecks are often done as a free service to the patient when in fact they could be billed to the patient's insurance.

The items needed to code for this Level of service are made up of the 3 components of the progress note.  For a new patient, all 3 components must be met.

This code can be utilized for items such as:

  1. A weight check for medications that can cause weight loss.

  2. A follow-up Blood pressure check without a physician present

  3. Discussion in person to discuss lab results.

  4. Suture removal following placement by another physician

  5. Diabetic counseling

  6. Dressing change for an abrasion

There are no specific items needed to code for this Level of service.

1.) History-

  1. History of present illness- Duration, location, severity, modifying factors, associated symptoms, context, quality and timing

  2. Past medical family and social history

  3.  Review of Systems – 14 recognized systems

  • Constitutional (e.g., fever, weight loss)

  • Eyes

  • Ears, Nose, Mouth, Throat

  • Cardiovascular

  • Respiratory

  • Gastrointestinal

  • Genitourinary

  • Musculoskeletal

  • Integumentary (skin and/or breast)

  • Neurological

  • Psychiatric

  • Endocrine

  • Hematologic/Lymphatic

  • Allergic/Immunologic 

2.) Exam- The physical exam component is comprised of  

  • Constitutional (e.g., vital signs, general appearance)

  • Eyes

  • Ears, nose, mouth, and throat 

  • Cardiovascular 

  • Respiratory 

  • Gastrointestinal 

  • Genitourinary 

  • Musculoskeletal 

  • Skin 

  • Neurologic

  • Psychiatric 

  • Hematologic/lymphatic/immunologic

3.) Medical Decision Making

  1. Diagnosis

  2. Treatment options- Medications, referrals, splints, etc..

  3. Data review – Old records, labs, medical tests, imaging, etc…

  4. Level of Risk – Minimal, low, moderate and high

For an established patient 99211 the following items must be met for any combination of two out of three components with no specific amount required.

  • History – no requirement

  • Exam- none.

  • MDM- no requirement

Example: 99211

27 yo male here rechecks of BP after starting lisinopril.

Vitals – BP 120/80

Diagnosis – HTN

As you can see from the above example it does not take much documentation to bill for a 99211 and it can be billed by non-physician staff.

The other option for billing for Evaluation and management codes is the unit of time.  For a 99211 the practitioner must spend at least 5 minutes face to face with the patient and half of the time spent counseling the patient on treatment, lab results, and planning.  All of these components should be documented.