Most information about documentation of evaluation and management (E/M) services is directed to physicians and other qualified health care professionals (QHCPs). However, clinical staff (eg, nurses, medical assistants, technicians) may also perform E/M services incident to the services of a physician or QHCP. These E/M services are reported with code 99211, office or other outpatient visit for the E/M of an established patient that may not require the presence of a physician or other QHCP.

Code 99211, unlike other E/M codes, is not selected based on the 3 key components of history, examination, and medical decision-making. Current Procedural Terminology (CPT®) further describes a 99211 service as usually provided for a presenting problem that is minimal, with 5 minutes spent performing or supervising these services.

Many payers cover 99211 services only when the service is provided in compliance with incident-to guidelines. The Centers for Medicare &...

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