Low Level Evaluation and Management Services - CPT 99211

WPS Medicare closely monitors Comprehensive Error Rate Testing (CERT) review findings to identify problem areas contributing most significantly to our error rate. Inappropriate billing of Current Procedural Terminology (CPT) code 99211 is one area of concern.

Below are examples of CERT reviewer comments in these cases.

  • Provider billed CPT 99211(25), established patient office visit which does not require the presence of a physician. The documentation received includes the PT/INR result, result of C- Difficile Toxin. No documentation to support the service billed (CPT 99211, evaluation and management of an established patient).
  • Submitted documentation includes progress note from previous week, and lab results. No medical documentation submitted to support the evaluation and management code billed.
  • Missing documentation to support any evaluation and management services were provided. Only documented service is a PT/INR sheet with typed vital signs, dosage, and typed initials and PT/INR results.
  • Submitted note states, "Draw CBC." This does not support a separately identifiable service from billed venipuncture on this claim.

Services billed to Medicare under CPT code 99211 must be reasonable and necessary for the diagnosis and treatment of an illness or injury. Furthermore, a face-to-face encounter with a patient consisting of elements of both evaluation and management is required. The evaluation portion is substantiated when the record includes documentation of a clinically relevant and necessary exchange of information between provider and patient. The management portion is substantiated when the record demonstrates an influence on patient care (ex., medical decision making, patient education, etc.).

CPT 99211 should not be used for:

  • Phone calls to patients
  • Drawing of blood for laboratory analysis or when performing other diagnostic tests
  • Administration of medications when an injection or infusion code is submitted separately

Your cooperation in proper documentation and billing of Medicare services is needed to reduce improper Medicare payments and meet the Centers for Medicare & Medicaid Services' (CMS) national error rate reduction goals. Continued CERT error findings may result in additional review by CMS, WPS Medicare, or Recovery Auditor (RA).

Page Last Updated: Thursday, 26-Apr-2012 15:58:33 CDT