EM Coding Alert

Question: Two neurosurgeons in our practice treated a post-trauma patient twice on the same day. In the morning, physician A prescribed new medication for a patient who’s been having occasional convulsions and coded the encounter as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).

Later that day, the patient returned with similar complaints and saw physician B, who performed and documented 99214 (….Usually, the presenting problem[s] are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family) with the treatment provided.

Can I bill both 99213 and 99214 on the same date of service for both of these encounters?

New York Subscriber

Answer: In this scenario, you have two physicians in the same group who are not in separate specialties (both are neurosurgeons in the same group). Both doctors see the same patient in the office on the same day. You cannot bill two separate codes for the same-patient, same-day services.

“While uncommon, two visits by the same or different physician may be medically appropriate,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison. “If more than half of the time spent with the patient is in counseling or coordinating care, one may combine the total time of both visits and report a higher level E&M service.”

Here’s why: Payers often consider working together as partners in the same practice and same specialty as one billing person. Even though the physicians have different NPI numbers, both bill under the practice’s tax ID number. Some payers to which you bill services on the same day but at different times will reimburse based on the date of service not on the time of day the service was performed on the same day. That means that the payer would consider the same-day services bundled (whether two E/Ms or an E/M and a procedure).

“If anyone’s tried to bill the two E/Ms on the same day by the same provider, or same specialty provider in the same specialty group, they know it’s just not going to get paid unless the doctor proves in their documentation that these are two distinct problems,” says Kris Cuddy, CPC, CIMC, Healthcare Compliance Analyst at Michigan State University HealthTeam in East Lansing, Mich.

You would normally combine both E/M services into one code. CPT® considers an E/M service’s history and physical global for the day. Therefore, correct billing bundles same-day office visits together. “This also means that the total time involved as well as the combined documentation can be used to determine the level of service that can be reported,” says Przybylski.

Official guidance: According to MLN Matters article MM4032, “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 headache following an accident).” You can read this article at www.cms.gov/mlnmattersarticles/downloads/MM4032.pdf.

Better way: Combine the two physicians’ work and submit one E/M code, such as 99215. Combine the E/M components of both visits and bill the higher E/M code. This must be carefully documented, however. “If most of the visit was spent in counseling and/or coordinating care for the patient, it may be better to report the combined time of both services to justify a higher level of service,” says Przybylski.

“It would behoove the physicians to combine their documentation and either bill a higher level E/M service for the total E/M services provided (and the practice would determine how to split reimbursement if that were an issue), or to look at the prolonged service codes (remembering it needs to be the physician face-to-face time with the patient that counts towards those codes),” Cuddy advises.

Caveat: If the second provider “only provided necessary treatment and did not perform a separate exam and medical decision making to determine the treatment was necessary, then there is no medical necessity to support E/M 99214,” warns Catherine Brink, BS, CMM, CPC, CMSCS, president of NJ-based Healthcare Resource Management. “If 99214 was indeed performed and documented, then the 25 modifier is needed.”

Important: Private payers may follow this rule, or might make their own payment guidelines. It is always safer to be aware of payer specific guidelines on this and make your physician aware of this.