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Ask-A-Consultant: Billing 99211 for Medical Assistant


I would like to know if a OV 1 for an established patient can be billed for (99211) when a patient comes in only for an injection (such as a B12 shot or testoterone injection) given by the medical assistant with the MD only signing off on the documentation of the encounter, but not seeing the patient (MD is in or out of the office when the encounter occurs).

Also, can a 99211 visit be billed for when the medical assistant does an in office PT/INR and documents the visit which the MD signs off on (again with the MD in or out of the office when the encounter occurs).

What criteria must be fulfilled to bill a 99211 when the patient is not seen by the MD?

Lawrenceville, GA


This is actually a multipart question, so we would like to look at each scenario independently.

First, in no case can you bill 99211 when the physician is out of the office. This service is an incident-to service which requires the direct supervision of the physician. Medicare defines direct supervision as on-site supervision by the physician. Although the physician does not need to be physically present in the room where the services are being provided, he/she must be in the office suite and immediately available.

Second, when a patient comes to the office specifically for an injection such as B12 or testosterone, it is not appropriate to bill an office visit code in addition to the administration code and drug code. This rule applies to minor procedures as well. If you have scheduled the patient to come in for a specific procedure, the E/M service is already included in the procedure. With regard to the medical assistant administering the injection, you may bill only the administration code and drug code if the physician is not present.

Third, if a patient comes into the office for follow-up lab work, the medical assistant may bill 99211 in addition to the lab tests as long as the documentation includes the chief complaint, vital signs, any notations of changes the patient has experienced since the last visit and who ordered the lab work. Again, the physician must be in the office suite in order to bill both 99211 and the lab tests. If the physician is not in the office, only the lab tests should be billed.


Mary Beth Black, CPC
Senior Associate

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