Office or other outpatient visit, established patient, level 1
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Nurse visit without physician supervision documentation
Common99211 is often used for nurse visits, but requires documentation that the visit was performed under physician supervision and that the physician is immediately available if needed.
Common Causes
- • No documentation of physician availability/supervision
- • Visit performed when physician was not on-site
- • No clear indication nurse was following physician's care plan
Resolution Strategy
Document physician supervision (on-site and immediately available) and that visit followed physician's care plan. Resubmit with enhanced documentation.
2. No face-to-face encounter documented
Common99211 requires an actual face-to-face encounter with clinical staff. Phone calls, portal messages, or prescription refills without a visit do not qualify.
Common Causes
- • Telephone encounter coded as office visit
- • Patient portal message consultation billed as visit
- • Prescription refill without patient encounter
Resolution Strategy
If face-to-face encounter occurred, document it clearly. If no encounter, charge should be removed or coded differently (e.g., 99441-99443 for phone).
💬 Plain Language Explanation
What this means
This is a brief office visit, often for simple tasks like getting a shot, having a blood pressure check, or picking up a prescription.
Why you might see this
This is the lowest level of office visit code. You might see this for very brief visits that don't require much medical decision-making, such as routine injections, simple follow-ups, or administrative tasks.
Common context
Used for very brief, simple visits that require minimal medical evaluation.
What to ask your provider
"'Was this a brief visit for a simple task, or should it have been coded as a more complex visit?'"
Relative Value Units (RVUs)
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Clinical Information
When to Use
Brief established patient visit requiring minimal medical decision-making or 5-9 minutes total time
Common Scenarios
Documentation Requirements
- Chief complaint or reason for visit
- Brief assessment of problem
- Plan documented
- OR document 5-9 minutes total time with activities performed
Coding Guidelines
Common Modifiers
Bundling Rules
- Often supervised by physician but performed by clinical staff
- Cannot bill if no face-to-face encounter occurs
Exclusions
- Do not use for new patients (use 99202-99205)
- Do not use if time is 10+ minutes (use 99212 or higher)
Coding Notes
Clinical scenarios
- Chief complaint or reason for visit
- Brief assessment of problem
- Plan documented
- Chief complaint or reason for visit
- Brief assessment of problem
- Plan documented
- Chief complaint or reason for visit
- Brief assessment of problem
- Plan documented
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PFSRVU Breakdown
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Frequently Asked Questions
CPT 99211 is the billing code for "Office or other outpatient visit, established patient, level 1". Brief established patient visit requiring minimal medical decision-making or 5-9 minutes total time
Medicare pays approximately $22.64 for CPT 99211 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 99211 has a total RVU of 0.84, broken down as: Work RVU 0.18, Practice Expense RVU 0.61, and Malpractice RVU 0.05. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99211 is "Nurse visit without physician supervision documentation". 99211 is often used for nurse visits, but requires documentation that the visit was performed under physician supervision and that the physician is immediately available if needed. Common causes include: No documentation of physician availability/supervision; Visit performed when physician was not on-site. Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 99211 include: Chief complaint or reason for visit; Brief assessment of problem; Plan documented; OR document 5-9 minutes total time with activities performed. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99211: Often supervised by physician but performed by clinical staff. Cannot bill if no face-to-face encounter occurs Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 99211 include: 25 (Significant, separately identifiable E/M service on same day as procedure). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 99211 is 5-9 minutes total time on date of service. Time-based codes require documentation of the actual time spent providing the service.