Medical Billing Forum

Coding => Coding => Topic started by: Zeecy on November 10, 2009, 09:02:01 PM

Title: patient did not see doctor
Post by: Zeecy on November 10, 2009, 09:02:01 PM
I have some cases where a patient comes in just for a weight & height check & is only seen by the nurse.  The staff is putting the encounter into the system, usually a 99212, with a note that the patient didn't see the doctor.

Another case would be where the patient came in for a throat culture.  I don't know why they would not see the doctor but it seems to sometimes happen.  Do I bill for the throat culture but not for a visit?

I can't delete the encounters, but can I bill for them?  If so, how?
Title: Re: patient did not see doctor
Post by: oneround on November 11, 2009, 11:09:13 AM
According to the CPT manual, a 99211 is an office or other outpatient visit "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." Unlike the rest of the office visit codes, 99211 does not have any documentation requirements for the history, physical exam or complexity of medical decision making.

The cost to standardize nursing documentation is minimal: a few copies of a form per year. 
None of these visits requires the presence of a physician in the exam room (although the physician should be on the premises). In fact, as a rule of thumb, a physician should not code a 99211. What these visits do require is supporting documentation, so if you plan to charge for nurses' visits, you need to train your nurses to provide very basic medical documentation. I have found the most successful method for achieving adequate and consistent documentation from nurses is to make simple, check-box-driven forms, which guide nurses' decision making, protect you from litigation and give you the clinical data you would want yourself.
Title: Re: patient did not see doctor
Post by: Zeecy on November 11, 2009, 12:53:03 PM
Thank you!  That is good to know.  I usually do have the documentation for the visits, but did not know how to deal w/ the fact that the doc didn't see the patient.