According to the CPT manual, a 99211 is an office or other outpatient visit “that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services.” Unlike the rest of the office visit codes, 99211 does not have any documentation requirements for the history, physical exam or complexity of medical decision making. The nature of the presenting problem need be only “minimal,” such as monthly B-12 injections, suture removal, dressing changes, allergy injections with observation by a nurse, and peak flow meter instruction. (For more examples, see Appendix D of the CPT manual.)

Scenario. In our outpatient hospital wound care setting, the subsequent wound care sessions consist of wound care dressing changes by the RN usually 20 sq cm area of wound, ankle brachial pressure index readings by the RN for 15 minutes, and a referral back to the surgeon for his advice/opinion on the case. The surgeon (MD) signs off on the clinical documentation of the encounter. The entire session lasts no less than 25 minutes, and on average 30 minutes. Will still be considered a 99211 billing?

Please advise.

Thank you again.