Gastroenterology Coding Alert

Question: We are having trouble with claims being denied for hospital follow-up visits on the same patient by two different doctors. The physicians are not in the same group or specialty. Do most people receive notes and appeals from insurers? Are there guidelines to follow?

Oregon Subscriber

Answer: Medicare's policy on multiple inpatient visits by physicians in different specialties is pretty straightforward. According to section 15505, if the two physicians are each responsible for different aspects of the patient's care, are from different specialties, and use different diagnosis codes, then both should receive payment.

Your problem could be the diagnosis code the doctors are using. For example, a gastroenterologist sees an inpatient for a GI bleed, and the primary-care provider (PCP) sees the same patient for other problems, including hypertension. Only one physician should report the GI bleed as a diagnosis code. You should code for the E/M service (99231-99233, Subsequent hospital care ...) along with the diagnosis code for the GI bleeding (578.9). The PCPshould code the appropriate E/M code along with diagnosis codes for the hypertension (401.x) and any other conditions.

If you are already reporting separate diagnosis codes and still not receiving reimbursement, then the problem might be with your carrier. Some private carriers do not enroll providers with specialty numbers. When you have problems with this scenario, call your carriers to see if they will reprocess your claim after they see that the services were from different providers. If they request an appeal, then do so. This is not uncommon.