CPT codes play a critical role in medical billing. Using the wrong code in the wrong place or for an incorrect type of diagnostic or treatment process can lead to potential claim rejections and denials. Not to mention a very serious risk of delays in your practice’s revenue stream.

One of the CPT codes that come under scrutiny by some insurance providers and public health institutions is the 99211 CPT code. Though knowing precisely when to use this 99211 CPT code can help you boost your accepted number of claims as well as promote timely, and consistent reimbursements in your practice’s revenue stream.

In the realm of mental and behavioral health medical billing, knowing how to properly apply specific codes to the services rendered plays an essential role in maximizing your revenue. With every patient visit, there are services rendered, whether it is for a consultation, an evaluation, some form of psychotherapy, diagnostics, or other services. Each of the services rendered has a specific code associated with it for medical billing.

Clearly understanding these codes is critical. If you accidentally identify a service using the wrong code, insurance payers will make sure that claim is denied, delaying your reimbursement. This is especially true when it comes to unintentional misuse of the 99211 CPT code.

The following guide will help you get a better understanding of when and how to properly use the 99211 CPT code when filing a medical billing claim.

What Is The 99211 CPT Code?

In short, the 99211 CPT code is a part of an insurance billing procedural code that describes a rendered service such as an “Evaluation & Management” at a clinical office or for an “Outpatient Visit” with an established patient.

Though it is important to note about this 99211 code that it is considered an evaluation and management visit and that this visit needs to be with an already established patient. This specific evaluation & management visit can also be rendered by an ancillary of the client’s provider where it would then be billed as though that provider is the one rendering the services. You should also note that while the 99211 CPT code is typically used in this manner. If the visit is being conducted by the psychiatrist or psychotherapist themselves, then a different code or codes would then be used.

How Long Is The Evaluation & Management Visit Allowed to Last?

By definition, the 99211 CPT code is to be billed for Evaluation & Management visits that last no longer than 5 minutes. These visits are typically used by an ancillary to the client’s psychiatrist such as by a registered nurse. If the Evaluation & Management visit happens to last longer than 5 minutes then it needs to be billed and linked to another CPT code. This might include the following scenarios.

  • The 99212 CPT Code should be used for an evaluation and management visit lasting no longer than 10 minutes.
  • The 99213 CPT Code should be used for an evaluation and management visit lasting no longer than 15 minutes.
  • The 99214 CPT Code should be used for an evaluation and management visit lasting no longer than 25 minutes
  • The 99215 CPT Code should be used for an evaluation and management visit lasting no longer than 40 minutes.

The specific code used as well as the duration of the visit will typically be linked to the client’s symptoms or their underlying conditions. The lesser the client’s symptoms, the shorter amount of time the visit will typically take.

Requirements For Using The 99211 CPT Code

It’s important to keep in mind that not every billing code can be used over and over again. Many codes have limitations, and specific requirements that are carefully observed by insurance payers, and public health institutions. When using the 99211 CPT code, you need to be mindful of the following stipulation.

Billing Frequency

With the 99211 CPT code, the billing frequency allowed is dictated by the patient’s insurance. It’s also important to remember that Medicare providers can also use this billing code. So, be sure to check with the client’s insurance to make sure what their stipulated limit is for using the 99211 CPT code and how often you are allowed to bill it.

Must Be An Established Patient

The allowable use of the 99211 CPT code is specifically for existing patients. It cannot be billed for a new patient. If you do happen to use it for a new patient the claim will most likely be denied by the patient’s insurance provider.

The Visit Must Be In-Person

These days In-person means different things. With the advent of telehealth and zoom sessions for things like mental health groups or talk therapy a face-to-face video meeting is allowable. However, the 99211 CPT code cannot be used for service rendered over the phone.

For Evaluation & Management Purposes

The use of the 99211 is strictly meant for evaluation and management purposes. This can mean that the client’s history was discussed or reviewed or that some other type of assessment took place. The information gathered from this discussion then lead directly to decisions that were made regarding the client’s care. A clinical need must be identified and treated.

Bill Separately

In a case where you are rendering additional services, on that same day, then you need to bill the 99211 CPT code separately. Essentially the 99211 CPT code cannot be used in a bundled billing service.

There are a few important components required in the subsequent CPT codes 99212 through 99215, that don’t specifically follow the same requirements for the 99211 CPT code. It only needs to have enough information for why the service was rendered, when, for what reason, and any other relevant information.

Accurate Coding With Expertise

Claim denials can be a major waste of time and can cause significant inconsistency in your practice’s revenue stream. When you outsource to a professional third-party medical billing specialist like Operant Billing Solutions, you can trust that highly trained and experienced medical billing and coding experts are keeping a keen eye out for errors. This includes the incorrect use of things like the 99211 CPT code or instances when one of the codes 99212 through 99215 would be more appropriate.

Not only does this reduce your risks of claim denials and delays, but it frees you and your administrative staff up to stay focused on treating patients or expanding the scope of your practice.