Physician Presence Matters in Outpatient Setting

Question: I have an OB/GYN that monitors patients in the observation area of the hospital undergoing fetal stress testing. The nurse's notes indicate communication with the doctor as far as orders, discharge, etc. The doctor does not physically see that patient. Can I use a 99211 for this -a nurse visit?

Answer: This question brings a couple of concepts into play - it's actually kind of a hard question. On the one hand, a 99211 is payable in the outpatient hospital setting, which would include a partial OB setting. So if the physician is present in the clinic, and we have a record of the interaction between the physician and the nursing staff - beyond the orders section of the chart - we could have a 99211. The lack of face-to-face service rules out a 99212 or higher level of physician service. The higher documentation standard would include a physician note describing his/her cognitive services relative to the patient.

The question gets deeper if the physician is not present in the clinic. From your mention of "communication" and "does not see the patient," I'm wondering if the physician is around at all.

Medicare could take the position that since there was no presence, and no face-to-face interaction, that an "encounter" did not occur.

When answering a question like this many coders will start talking about "incident-to." While incident-to is a convenient concept to lump such encounters under, it does not apply in a hospital setting, inpatient or out. An operative element of incident-to is that the nonphysician provider of services is an employee of the physician.

According to one carrier, the physician bills 99211 when evaluation and management services are furnished to a physician's service by a nonphysician employee of that physician.

This is certainly not the case in the hospital setting. So presence matters, but not from the incident-to perspective.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This question originally appeared in the January 2011 issue of Physicians Practice.