Gastroenterology Coding Alert

Question: If a patient was seen for an office visit (99214) first and then later on the same day went to the hospital emergency room and was seen again by the same physician (99284), would both visits be payable by Medicare?

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Answer: The answer depends on how the emergency room first visit came about. 

If the doctor says during the office visit that the patient should go to the ER, then you should combine the work of the two services and report just one code — the 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity) in this case. When the two services are related to the same symptoms or condition then it may be best to combine the services into one code and even one note. Because there will be a considerable amount of time spent coordinating the care the patient receives it may also be best to use total time as the basis for choosing the level of service.   Be sure to document in the note that the service was initiated in the office and that care continued later in the ER. 

However, if the services were truly separate encounters for unrelated symptoms or conditions, you can report 99214 and then the appropriate ER E/M code, such as 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity). You will need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). Both services need to be medically necessary/relevant and thoroughly documented.