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Do Nurse Visits Count as Encounters?

October 21, 2013

It really doesn’t matter where we speak or to whom we are
speaking, at EVERY PMG presentation someone will ask about nurse visits and
encounter rate. The question is quite simple….really. A nurse visit (or 99211)
is not a qualifying visit. And here’s why; Medicare pays all-inclusive rate per covered visit. Well, why then
isn’t a visit with a nurse paid at encounter rate? Because Medicare defines a
visit as “a face-to-face encounter between the patient and a physician,
physician assistant, nurse practitioner, certified nurse midwife, visiting
nurse, clinical psychologist or clinical social worker during which an FQHC
service is rendered.”
A nurse is not listed as a qualifying provider in an
FQHC. That is not to say the service the nurse provides is not necessary nor
that it is clinically inappropriate. They may very well be the most appropriate
provider for the service. These visit are just not reimbursable in an FQHC by

The cost of providing this service is reported on the
clinic’s annual cost report. Medicare allows for this cost in the calculation
of your encounter rate.

As for Medicaid? That varies from state to state. Don’t guess! Find out for
sure. Most Medicaid programs recognize the same core providers as Medicare. If
they do allow nurse visit to be paid at an encounter rate, it is usually
limited to a specific service type. Be careful!

Now don’t throw those nurse visits away! Capture
the charge and the revenue when you can. Nurse visits (99211) are reimbursable
by your commercial payers and something should be collected from your self-pay

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