Orthopedic Coding Alert

Question: Our practice employs seven orthopedic surgeons, each of different specialty, such as hands, knees, shoulder, spine, etc. If a patient first sees one orthopedic surgeon within the practice for a knee problem and then is referred to another doctor within the practice for a shoulder injury, should we bill the second E/M that day as an established visit or as a new patient visit?

Nevada Subscriber

Answer: You probably can't bill the second E/M at all, assuming that both physicians are designated as specialty 20 (orthopedic surgery) with the insurer. Your physician registered his specialty when he contracted with the insurer, and the payer licensed him to bill the insurance company.
 
When two physicians of the same specialty at the same practice see a patient on the same day, the insurer will deny the second E/M service that you bill on that date. Payers limit your option to one E/M service per day per specialty in the same group practice.
 
But if your spine surgeon is designated as specialty 14 (neurosurgery), you should be able to report the second E/M visit because the insurer would consider the physicians to be different specialties. And in some cases, the second visit might be billable as a consultation because the first surgeon might request the subspecialist's opinion on a patient's condition. Some orthopedic practices have orthopedic surgeons on staff, as well as hand surgeons (specialty 40), podiatrists (specialty 48), neurosurgeons, and physiatrists (specialty 25).
 
Just for the record, if a general orthopedic surgeon in your practice sees a patient for a knee injury and, the following week, a different orthopedic surgeon examines the patient for a shoulder problem, the second visit would be considered an established patient E/M (99211-99215) because another physician of the same specialty at the same practice saw the patient within the last three years.