“Three of the podiatrists in our group have joined together to open a wound care center. They have a licensed LVN on staff that performs wound dressing changes, Arobella wound care treatments and things of that nature. Are we able to charge the E/M code 99211 as a "nurse" visit if the doctor is not on site? Any advice or recommendations are greatly appreciated.”
First of all, an LVN, or Licensed Vocational Nurse, provides basic medical care to sick, injured, or disabled patients under the supervision of a doctor or registered nurse. In some states, this same role is called a Licensed Practical Nurse (LPN). With respect to Arobella wound care treatments, if the Arobella device is being used at low power purely for misting, cleaning, irrigation, or superficial wound management, it falls under basic wound care. Most states allow an LVN to perform this under a physician's direct orders, but it depends heavily on your state's nursing laws and how the procedure is classified.
The answer depends on the payer and whether Medicare's direct supervision requirements are met.
For Traditional Medicare (2026):
Yes, E/M code 99211 may be billed even if the physician or podiatrist is not physically in the office, provided the supervision requirements are satisfied.
Beginning January 1, 2026, CMS permanently expanded the definition of direct supervision to allow it to be furnished through real-time, two-way audio and video technology (audio-only is not sufficient) for most incident-to services, including CPT code 99211.
Therefore, for a Medicare patient:
- The service is furnished by qualified auxiliary personnel (e.g., nurse, MA, LPN, RN) as an incident-to service.
- The physician/qualified practitioner established the patient's diagnosis and plan of care.
- The supervising physician or practitioner is immediately available either:
1. physically in the office suite,
2. or virtually through real-time interactive audio-video technology (if all Medicare requirements are met).
- The service is medically necessary and documented.
Under these circumstances, 99211 may be billed even though the physician is not physically on site.
WhenE/M code 99211 Cannot Be Billed:
You generally cannot bill 99211 if:
- There is no supervising physician or qualified practitioner immediately available (either in person or through compliant real-time audio/video supervision for Medicare).
- The visit is the patient's initial visit, and no physician has established the diagnosis and treatment plan.
- The nurse independently evaluates or changes the treatment plan.
- The visit does not meet incident-to requirements.
- State law or payer policy requires stricter supervision
It is important to note the following: CPT code 99211 should not be billed with modifier 25 if a procedure such as Arobella wound care is performed on the same date 0f service. Because 99211 is a minimal, staff-level service with a "nil" or minimal level of medical decision-making that typically does not meet the threshold of a significant, independent E/M service, major payers and coding authorities explicitly state that modifier 25 does not apply to code 99211. Furthermore, routine clinical tasks or procedures performed by an LVN/LPN under physician supervision are generally bundled into the primary procedure or the primary visit code itself.
Important Caveat for Commercial Insurance:
Many commercial insurers do not automatically follow Medicare's 2026 virtual supervision policy. Some still require the supervising physician to be physically present in the office before they will reimburse a nurse visit billed as 99211.
For that reason, practices should verify each payer's policy before routinely billing 99211 when the physician is off site.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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