Oncology & Hematology Coding Alert

Question: Two physicians in our group saw the same inpatient on the same date. The first visit was in the early morning by a doctor on call. The second doctor saw the patient during the day. How do I report these same-day visits?

Codify Member

Answer: Payers following Medicare rules expect to see physicians of the same specialty and in the same group billing as a single physician, so you should report a single E/M code that takes the combined work of the two doctors into account. There’s an exception for outpatient visits if the two visits are performed for unrelated problems. For example, a patient has a follow-up visit in the morning, leaves, sustains an injury, and returns to the office on the same date. 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) would be appropriate on the second E/M. You may have to appeal and provide supporting documentation when reporting two E/M codes for the same date. Two visits for an inpatient would be combined as they are “per day” codes.

Support: The Medicare Claims Processing Manual (MCPM), Chapter 12, provides several relevant instructions. You’ll find it online at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf.

General: Section 30.6.5 provides this general E/M instruction about physicians in a group practice: “Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group.”

Inpatient: Section 30.6.9 is specific to inpatient visits, and 30.6.9.A states, “Both Initial Hospital Care (CPT^® codes 99221-99223) and Subsequent Hospital Care [99231-99233] codes are ‘per diem’ services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.”

Section 30.6.9.C adds that “In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, contractors do not pay physician B for the second visit. The hospital visit descriptors include the phrase ‘per day’ meaning care for the day.”

Different specialties? The manual provides different rules for physicians of different specialties, so be sure to review the full section to see which rules apply to each specific case.