ED Coding and Reimbursement Alert

Question: We saw a patient in the morning for a bloody nose and then he came back in the afternoon because it was bleeding again. How do we report two separate ED visits on the same date?

Codify Subscriber

Answer: Although it’s tempting to report two different codes for the separate services, that’s not always the best approach. A frequent approach is to roll both visits into one code, adding together the notes from both to establish the level of service to report.

The reason is that payers will not typically reimburse you for two related E/M visits on the same date of service. It doesn’t matter what modifier you use, unless there’s a different diagnosis, you frequently won’t be successful in billing both visits separately.

Many payers will reimburse you separately for both visits if they are for two different problems. For instance, if a patient presents in the morning after falling out of a tree and breaking her arm and then comes back again in the afternoon with an asthma attack, you may be able to collect for both.

The Medicare Claims Processing Manual states in chapter 12, “The Medicare Administrative Contractors (MACs) 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, off campus-outpatient hospital, or on campus-outpatient hospital setting which could not be provided during the same encounter.”

Do this for unrelated visits: Part B MAC Palmetto GBA offers the following recommendation for those that do report two E/Ms on the same date to describe separate diagnoses: “If the reason for the second visit is an unrelated problem that could not have been addressed in the first encounter, the reason for the second visit must be clearly documented in the documentation field of the electronic claim or as an attachment to the CMS-1500 Claim Form.”

If procedures are involved in one or both visits on the same day, you may be able to report procedures in the second visit, or even repeated procedures using modifier 76 (Repeat procedure or service by same physician or other qualified health care professional).