General Surgery Coding Alert

Question: The surgeon saw a patient in the office (99214), but later in the same day, saw the same patient again in the emergency room (99284). Can we bill both codes to Medicare?

Utah Subscriber

Answer: That depends on why the emergency room visit occurred.

If the surgeon says during the office visit that the patient should go to the ER and that he will see the patient later that day in 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.

However, if the services were truly separate encounters, 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) to 99214. Both services need to be medically necessary/relevant and thoroughly documented.

Caveat: Although billing both E/M services is acceptable in the last scenario, you’ll often get an initial denial and need to file an appeal. You might want to consider the cost of appeal versus the possible reimbursement before proceeding.