CPT Code 99211: Office or Other Outpatient Visit for Established Patients

What is the 99211 CPT code?

CPT 99211, defined as "office or other outpatient visit of the evaluation and management of an established patient that may not require the presence of a physician," represents a minimal-service outpatient evaluation and management (E/M) visit for an established patient.

It does not require the presence of a physician and is often used to report services rendered or services performed by other clinical staff members, such as simple follow-ups, such as blood pressure checks, medication refills, or minor wound care.

Do note that if the aforementioned healthcare providers conduct activities such as checking the patient's vital signs prior to the patient's office visit with the supervising physician or give the patient instructions after a physician's minor procedure, the said activity will be part of the E/M service of the physician.

CPT code 99211 documentation requirements

For more accurate coding, here are all the requirements healthcare professionals must document before using CPT code 99211:

• Chief complaint or reason for visit to support the encounter and service
• Relevant history, assessment, etc.
• Details or information on the date and provider in the office suite that provides the services
• Any interventions performed

CPT code 99211 billing guidelines

Using CPT code 99211 is pretty easy and straightforward, even though, in general, billing guidelines tend to be complicated and confusing. Here are some guidelines you have to keep in mind if you plan to use the 99211.

• Only for established patients
• E/M services, like a review of the patient's history or conducting a limited physical assessment, can be performed by nursing staff under physician supervision
• Time-based coding is not applicable

Other relevant CPT codes

• 99212: Slightly more complex E/M visit