Internal Medicine Coding Alert

With effort, you can get payment for unrelated problems
 
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.

Myth: 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."

Reality: 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 difficult.

Unrelated problems are 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: The patient arrives early in the day with pain in the lower abdomen. The internist examines the patient, diagnoses a hernia (for example, 550.9x, Inguinal hernia, without mention of obstruction or gangrene) and recommends surgery.

Several hours later, the patient's wife brings him back to the internist's office, stating that while shopping nearby the patient tripped and hurt his ankle severely and now cannot walk. The physician sees the patient in the office on an "emergency" basis and performs a second E/M related to the new complaint.

In this case, the internist 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 claim no matter how different the diagnoses.

Bulletproof Your Documentation

Most likely 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.

Ask yourself if it's 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 co-payments," 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. Also, 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, the internist diagnoses a patient with hernia and arranges for the patient to see a surgeon next week.

That afternoon, however, the patient returns to the office complaining that the discomfort has become painful, but there are no signs or symptoms of  increasingly worse incarceration.

Now the physician communicates with the surgeon to arrange for surgical evaluation the next morning.

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 internist'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 better defend your claim 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.