Gastroenterology Coding Alert

Unrelated problems on the same day could lead to separate E/M services

If a patient visits your office twice on the same day, you may be able to report two separate E/M services, but you-ll have to put forth additional effort if you expect the payer to recognize your claim.

Misconception: Many coders believe that you can't bill Medicare for more than one E/M visit on the same day, and that you should combine two or more visits into one. Indeed, Medicare transmittal 1644 (August 1999) specifies, -Pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not.-

The facts: Although the above rule holds true for the hospital, payers will allow for exceptions in the office setting, experts say. You may report multiple in-office E/Ms on the same day--but it can be an uphill battle.

Unrelated Problems Are the Key

Medicare will pay for two office visits by the same physician for the same patient on the same day if the visits are for unrelated problems, according to the Medicare Claims Processing Manual.

Example: A primary-care physician refers a patient to your gastroenterologist to check for Crohn's disease. The patient has a history of chronic abdominal pain in the lower right quadrant and diarrhea. Based on the findings of a level-two consultation service, the gastroenterologist schedules the patient for a colonoscopy at a later date.

You should report 99242 (Office consultation for a new or established patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision-making) for the consultation.

Several hours later, the patient's wife brings him back to the physician's office, stating that while shopping nearby, the patient tripped while experiencing severe chest pains. The physician sees the patient in the office on an -emergency- basis and performs a second E/M (for example, 9921x, Office or other outpatient visit for the evaluation and management of an established patient ...) related to the new complaint.

The GI is relieved to tell the patient that the problem is only severe heartburn, and therefore does not recommend hospital admission or other immediate services.

In this case, the physician sees the same patient twice on the same day for unrelated problems. At each visit the physician has to provide a complete evaluation. Such cases are rare, but when they arise, you could be justified in reporting two separate E/M services.

Important exception: Whenever the E/M code descriptor specifically lists -per day- (for instance, 99218, Initial observation care, per day, for the evaluation and management of a patient ...), you must include all E/M services for that date in the service no matter how different the diagnoses.

Consider Your Options

Chances are, your carrier will deny claims for two E/M visits on the same day, says Phyllis Klein, president of PK Administrative Services in Englewood, Colo. Unless the physician needs to use a critical care code (99291-99296) in the office or reports prolonged care (99354-99357) in addition to the E/M code, the carrier probably won't know what to make of it, Klein says.

Is it worthwhile?: -You-re going to have to send documentation, you-re going to have your payments delayed, and the patient's going to have two copayments,- says Barb Pierce with Professional Management Midwest in Omaha, Neb. In the end, the reimbursement will be higher than for one E/M service, but it will be hard-won money. In some cases, you may simply be better off combining the visits, even if they are for unrelated problems.

Combine E/Ms for Same Day, Same Problem

If the patient comes back the same day with an exacerbation of the same problem, you should definitely combine the two visits, and you can probably claim a higher-level service because of the added history and decision-making--as long as your documentation supports the added effort--Pierce says.

Example: In a case similar to the above example, a patient with a history of heartburn reports with severe heartburn six weeks after his last appointment, during which the gastroenterologist had recommended some lifestyle changes aimed at reducing the heartburn. That afternoon, however, the patient returns to the office complaining that the pain has become increasingly worse.

In this case, because the chief complaint is the same, you could -combine- the morning and afternoon E/M visits into a single visit at the level supported by the physician's documentation (such as 99214, Office or other outpatient visit for the evaluation and management of an established patient ...).

Exceptions can occur: In at least one case in which  an exacerbation later in the day was serious enough, however, Wenatchee Valley Medical Center has been able to convince the payer to reimburse both E/M services separately, says Connie Stevens, compliance officer and reimbursement manager.

-It's not a hard-and-fast rule that you can't bill two visits in one day when you-ve got appropriate documentation to support both claims,- Stevens says.

Bottom line: If you choose to combine two visits into one, don't automatically raise the level of the combined visit to a level five, or the insurer will most likely downcode your claim, says JoAnn Baker, CCS, CPC-H, CPC, CHCC, with Precision Coding and Compliance in Hackettstown, N.J.

To defend your claim better when combining multiple, same-day E/M visits into a single service, be sure to mention any comorbidities or exacerbations in the patient's condition to help justify the higher level, Baker says.