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Unlike other office visit E/M codes, the
documentation of a 99211 visit does not have any
specific key-component requirements. Rather, the note
just needs to include sufficient information to support
the reason for the encounter and E/M service and any
relevant history, physical assessment and plan of care.
The date of service and the identity of the person
providing the care should be noted along with any
interaction with the supervising physician.
Some practices create templates for the nurse to use
when documenting these encounters. The templates can be
specific to the reason for the encounter, such as a
template for a follow-up blood-pressure check, or they
can be generic forms that provide space for the
suggested documentation components. |
