Modifier Coding Alert

Question: I code outpatient hospital services for a multispecialty physician clinic that treats cancer patients. When a patient reports to the hospital, they often see more than one physician. For example, an established patient with colorectal cancer recently reported to the hospital clinic for a checkup. Notes indicate that he saw an oncologist, who performed a level-four E/M service. In a separate encounter later that day, our gastroenterologist also saw the patient and also performed a level-four E/M service. Can I code for each E/M service, even though they occurred on the same date?

Montana Subscriber

Answer: If you are coding in an outpatient hospital setting (e.g., emergency department, clinic, etc.), you can report multiple E/M services on the same day if the E/M services are truly separate. Since this patient saw a gastroenterologist and an oncologist, you should report two E/M codes.

On the claim, report 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) for the oncologist’s service. Then, report 99214 again for the gastroenterologist’s E/M with modifier 27 (Multiple outpatient hospital E/M encounters on the same date) appended to show that you are coding for two separate (hospital outpatient) E/M services.

Pointer: Check with your top payers to see what their policies are around this modifier. Because there were two specialties involved, the modifier might not be necessary.

Caveats: CPT^® created the modifier strictly for hospital outpatient services. Do not use modifier 27 when coding for physician practices. Also, you can only append modifier 27 to the following codes:

• 92002 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient) through 92014 ( … comprehensive, established patient, 1 or more visits);
• 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making) through 99499 (Unlisted evaluation and management service); and
• G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and G0175 (Scheduled interdisciplinary team conference [minimum of three exclusive of patient care nursing staff] with patient present).

Also, an additional caveat to this is that CPT^® designed modifier 27 to draw attention to any second (or third, or fourth) outpatient hospital visit in the same hospital or system, so that the payer doesn’t think you’ve reported multiple E/Ms in error.

---