# 2 E.D. visits same day 99283/99284



## mmunoz21

Is the E.R. doctor allowed to bill 2 E&M on the same day? patient came in the morning, dx:colitis, came back in the evening same day with vomitting/nausea...


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## devireddy

Hi,

Yes you can bill two visits.


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## spstarke

*only in certain circumstances...*

Hi there, 

My experience is actually quite different - I believe that there are *few *circumstances that allow you to bill 2 visits by the same specialty on the same DOS. i.e. I would not bill a 99283 and a 99284 on the same DOS for the same PT. My belief is that one E/M will be denied outside of certain situations. 
We get denials from visits where the PT has been seen in another ED on the same DOS, and I do not believe that the denials are dx related. 
An E/M and then Critical Care services on the same DOS are billable, in which case one would add a -25 modifier to the initial service. 

If a patient has 2 visits on the same DOS in our ED, we accumulate the time and effort from both visits and bill one E/M. In the event that someone has identifiable visits with different carries (i.e. bronchitis at 8am, and then back pain from an MVA at 10am - and therefore health and then MVA insurance), we bill those separately. With procedures, a -76 or a -77 modifier may apply, but those are worth exploring on a case-by-case basis. In my experience, even if we had a patient come in once with sinusitis and then later with a broken wrist from a fall at home, we would not bill two separate E/Ms.

From the CMS website (and I think it can be applied for ED as well - I could not unfortunately find explicit language about "2 visits in the ED on the same DOS", though that is the same as "two visits in the same specialty" so...):
 	"The Medicare Claims Processing Manual (Chapter 12, Section 30.6.7), Paragraph B, clarifies “physician in a group practice” for office/outpatient E/M visits provided on the same day of unrelated problems, are as follows:
• As for all other E/M services except where specifically noted, carriers may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office or outpatient setting which could not be provided during the same encounter (e.g., office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident)."
[from]  http://www.cms.hhs.gov/mlnmattersarticles/downloads/MM4032.pdf

Also, the discussion in the forum about critical care services and other E/M services on the same DOS may be helpful. 
I hope this helps...sorry if a bit long-winded.

*It would be great to see a reference either way (that it's explicitly ok in the ED, or not) - anyone have one? *

would love to know.
good luck!


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## mmunoz21

Thank you very much for all your info. it was great...


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## kak6

I am going to ask my supervisor how this process works for us because I have noticed that we have many return visits in the same day by the same PT. We do not use a modifier on the E/M though I will not be able to ask until Monday now. This is something I have wondered about myself when I see a return visit. One day recently I noticed the Dr had written on the record that this was the second visit this day so I checked the system for another visit and discovered this patient had been there 57 times in a two month period (psych case). To say the least this got me wondering how they were all paid. When I recieve an answer I will post it, if I get an answer.


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## kak6

Here is the way we proces a return visit within same date for the same DX. First the Dr needs to document the return visit or we would not recognize it as so, we do not check the system for each visit each pt. 
If it is for a commercial ins we code as usual and apply a modifier 25 ; for Medicare we void/no charge the entire visit. And thank you mmunoz21 for posting this question.


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## ansada

on the facility side we afix a modifier 27 on the second visit:


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## Davieda Skobel

*2 er visits same day*

We also combine the 2 visits. The CMS rule regarding paying 2 visits/ same specialty/same day does usually hold true unless the visits are totally unrelated. We look at both visit notes and combine the time and documentation and choose our level of E/M by that. ER physicians are usually in the same group so all the money goes to the same place anyway. Use both DX codes and if you have to appeal it, send both notes.


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## imai

Can anyone help?
How to code, if two ER visits are billed for same patient by same physician for same diagnosis on same DOS in different invoices?

Thanks,
imai


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## jimbo1231

*For same reason*

Many ED coding entities will combine the two visits based on total documentation and bill only once. The reason is usually that if a patient returns for the same reason or symptoms were not resolved, the hopsital will not want to penalize the patient for what may have been an oversite by ED providers,
also I believe many payors will not pay in the scenario you described based on medical necessity.
 If the pateint came in for an ankle sprain and returned for chest pain, that is a strong argument for billing twice. But in your scenario, better to combine. If you do bill twice use 25 modifier for physician and 27 for facility.

Jim S.


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## vicentevelasco2000

*Vicente Velasco, CPC-P*

As a payer here in Abu Dhabi, UAE we do collect deductible for all types of Consultation whether it is emergency or not.
My question is, if the provider billed two Emergency E&M wherein from the first E&M we already collected the deductible and since there is no follow up for emergency, is it right to collect another deductible for the second emergency visit?
Please note that the patient is complaining for the same problem, visited on the same day with four hours gap.
Does it matter if the patient was seen by a different emergency doctor?

Thank you very much!


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## CodingKing

That would depend on the patients medical plan benefits.


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## mk386

*E/M Question.. Can anyone explain correct answer*

The patient is a 35-year-old male who presents to the emergency department (ED) after several hours of low back pain, nausea, and chills. The ED physician takes a detailed history and performs a comprehensive examination. A urinalysis lab and CT of the abdomen is ordered. The results of the CT show two small kidney stones. The ED physician discusses the results with the patient and tells him the stones are small and will pass on their own. Medical decision making (MDM) of moderate complexity is made with the patient being discharged, with a prescription of pain medication, and with a diagnosis of kidney stones. Select the E/M code and diagnosis code(s).
1) 99283, N20.0
2) 99284, N20.0

Can anyone help me to get correct answer for this question with explanation?


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## kyannekis

We combine visits also unless the patient presents with a different problem.  Then we bill both visits.


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## Raulticascpc@gmail.com

*different e/m's*

I believe as long as its two diff dx, the modifier 24 can be used,,,, depending if unrelated procedures were done you may have to use mod 79,,,,, if it comes down to the same physician, same dos, same dx, with procedures, use mod 78, without procedures, modifier 25 is the one that fits best,,, hope this helps


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## mitchellde

alt9017@nyp.org said:


> I believe as long as its two diff dx, the modifier 24 can be used,,,, depending if unrelated procedures were done you may have to use mod 79,,,,, if it comes down to the same physician, same dos, same dx, with procedures, use mod 78, without procedures, modifier 25 is the one that fits best,,, hope this helps



Modifier 24 is used when the surgeon is seeing a patient in the post operative time for an unrelated diagnosis.  78 and 79 modifiers can never be used on E&M codes they are only for procedure codes.  If the payer will allow the physician to bill for two encounters on the same day, and most will not, then you would use the 25.  Facility billing is completely different .  A patient may return multiple times to the facility, ER or clinic and see the same provider.  And while the provider may bill only one E&M, the facility may submit multiple E&Ms on the same claim and I se the 27 modifier on the second and subsequent.  It does not matter for the facility if it was the same dx or different.


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## NIKI01

Hello,

2 Visits on same day for the same problem in ED dept. I am confused when pt. is staying overnight and then is coming back for same problem.
Example: PT. came in on 9/26 at 10:00pm for low back pain. and was discharged on 9/27 at 3:00am. then is coming back on 9/27 at 9:00am for low back pain again and nausea and then is discharged on 9/27 at 1:00pm.
I am assigning 2 facility levels with -27 on second level and I am assigning only 1 profee level on the second visit.
I am discussing this issue with my co-workers and we have a different view on this subject.


I would like to know other coders opinion. What should be taken under consideration admission date or discharge date when coding for 2 visits on same day on same problem?

Thank you so much for any help,
Niki


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## awyche0603@yahoo.com

Can ED Codes 99281 -99285 be used by other physicians who are not employed by the hospital? Are these codes reserved for ED staff only? All work is done in the ED.  Example: A patient comes into the ER with bladder pain. The ED Physician orders a CT and finds a bladder stone. The ED Doc calls a Urologist in to consult the issue.  The Urologist consults the patient and performs a Cysto to remove the stone. Can the Urologist bill a 99283 and 52310? Or should he/she bill 99203 and 52310?  The Urologists is rounding at the hospital that day.  

Thanks for all input
Andia


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## CRHN0819

Good morning,

I have a peds patient that was seen in the ED at 5am for severe ear pain, the pt was treated and released.  The patient has a a separate scheduled appt regarding behavior on the same day at 4pm.  The hospital and peds office have the same tax id.  Will the office be reimbursable since the child was seen in the ED on the same day of the scheduled unrelated appt?


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