Documentation Requirements for CPT Code 99211

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TrailBlazer Health Enterprises, LLC EDUCATION MAKES THE DIFFERENCE Published February 2008 DM CPT codes, descriptions, and other data only are copyright 2007 American Medical Association. All rights reserved. Applicable FARS/DFARS clauses apply. CDT codes and descriptions are copyright 2007 American Dental Association. All rights reserved. Applicable FARS/DFARS clauses apply. Documentation Requirements for CPT code 99211 CPT code 99211 is used to report a low-level Evaluation and Management (E/M) service. The CPT book defines code 99211 as: Office or other outpatient visits for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. code 99211 requires a face-to-face patient encounter; however, when billed as an incident to service, the physician s service may be performed by ancillary staff and billed as if the physician personally performed the service.

supervising physician. Documentation of a code 99211 service provided “incident to” should also indicate the supervising physician’s …

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