A few diagnostic tests can only be personally performed by a physician, such as gonioscopy or extended ophthalmoscopy. Most other tests have both a professional and a technical component because a technician or medical assistant is involved with the setup, patient instruction, and administration of the test. Then, the physician interprets the test results and writes a report. In most cases, the 2 parts — technical and professional — are billed together as a single global service with just 1 fee. In most cases, the work of the technician is not billed separately as an office visit on the day of the test; that work is part of the technical component of the test.

Sometimes, however, the physician instructs the technician to do more than just administer a test. Consider the following case: A phakic patient with a history of branch retinal vein occlusion was previously treated with laser. Subsequently, the patient received an intravitreal injection of triamcinolone acetonide. At the last visit, the exam found elevated intraocular pressure and early cataract formation, which comport with complaints of reduced vision and ocular pain for a steroid responder. A 10-2 visual field test was ordered at the earliest opportunity, with instructions to the ophthalmic technician to measure intraocular pressure and advise the retinal physician of the results.

Q. How is a technician visit defined?

A. Current Procedural Terminology (CPT) code 99211 defines a technician visit as, “Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional.”¹

Within the Centers for Medicare and Medicaid (CMS) Physician Fee Schedule and the associated National Correct Coding Initiative (NCCI) edit for 99211, the instructions on the day of a visual field are clear. The superscript “1” is attached to 99211, meaning the codes may be unbundled and billed under certain circumstances. Modifier -59 is used with 99211 to signify that special circumstances exist. Modifier -59 is used to identify procedures/services, other than evaluation and management, that are not normally reported together, but are appropriate under the circumstances.

Q. What documentation is required?

A. When billing CPT 99211, the documentation should include a written order detailing which components of the examination and testing services the technician must perform. It is crucial that:

• The physician’s order for the minimal office visit is entered in the medical record;
• The visit be medically necessary for the problem, condition, or injury;
• The work of the medical assistant for the visit is not part of the work for the concurrent diagnostic test; and
• The visit is performed with a supervising physician present in the clinic.

Besides the physician order for the technician visit, the physician must promptly review the technician’s notes and sign off on the exam, indicating concurrence and approval. The technician cannot change medications or instruct the patient to follow a different regimen than prescribed by the physician. In the event of an unusual, unexpected, or undesirable intraocular pressure measurement, the supervising physician on the premises will immediately examine the patient and make a new assessment and plan. Then, a higher-level office visit is billed for the physician’s exam, instead of a minimal office visit.

Q. What supervision is required?

A. Because the doctor’s auxiliary personnel are performing the service and are an incidental part of a physician service, the service must be performed under direct supervision as discussed in the Medicare Benefit Policy Manual, Chapter 15, §60.2:

• “In addition to coverage being available for the services of such auxiliary personnel as nurses, technicians, and therapists when furnished incident to the professional services of a physician, a physician may also have the services of certain nonphysician practitioners covered as services incident to a physician’s professional services….
• Services performed by these nonphysician practitioners incident to a physician’s professional services include not only services ordinarily rendered by a physician’s office staff person (e.g., medical services such as taking blood pressures and temperatures, giving injections, and changing dressings) but also services ordinarily performed by the physician himself or herself such as minor surgery, setting casts or simple fractures, reading x-rays, and other activities that involve evaluation or treatment of a patient’s condition.
• Nonetheless, in order for services of a nonphysician practitioner to be covered as incident to the services of a physician, the services must meet all of the requirements for coverage specified in §§60 through 60.1. For example, the services must be an integral, although incidental, part of the physician’s personal professional services, and they must be performed under the physician’s direct supervision.”²

Q. What does “direct supervision” mean?

A. Direct supervision in the office setting does not mean that the physician must be present in the same room as the technician. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the technician is performing services.

Q. What does Medicare allow for 99211?

A. The 2023 national Medicare allowable for CPT 99211 is $23.38. This amount is adjusted in each locality.

When patients present for diagnostic tests separate from a physician’s exam, usually only the test is billed. The work of the technician who performs the test is included in the allowed amount for the test. Occasionally, separate technician work is ordered by the physician and may warrant a separate charge. RP

REFERENCES

1. Current Procedural Terminology (CPT) Manual. American Medical Association; 2023.
2. Medicare Benefit Policy Manual, Chapter 15, §60.2. Services of nonphysician personnel furnished incident to physician’s services. Updated August 3, 2023. Accessed October 3, 2023. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c15.pdf