Otolaryngology Coding Alert

Remember that office visit coding isn’t always cut-and-dry.

Answer: In the scenario described on page 27, you are coding for the work of two physicians in the same group and specialty. Both doctors see the same patient in the office on the same day. You cannot bill two separate E/M codes 99213 or 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 …) for the same-patient, same-day services.

Here’s why: Payers often consider working together as partners / associates in the same practice and same specialty as one billing person. Even though the physicians have different NPI numbers, both bill under the practice’s tax ID number and group NPI. Some payers to which you bill services on the same day but at different times will reimburse based on the date of service. It does not matter how many times the service was provided on the same day. That means that the payer would consider the same-day services bundled together.

If anyone tries to bill the two E/Ms on the same day by the same provider, or same specialty provider in the same specialty group, it will not be paid unless the physicians prove in their documentation that your office is billing for two distinct problems.

“Often, many payers will not pay for two E/M services on the same day when your office can even provide proof that the two services are for two distinct problems,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J.

Official guidance: According to MLN Matters article MM4032, “Carriers MAY NOT pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office or outpatient setting which could not be provided during the same encounter (e.g., office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of headache following an accident).” You can read this article at www.cms.gov/mlnmattersarticles/downloads/MM4032.pdf.

Better way: Combine the two physicians’ work and submit one E/M code that encompasses all work, such as 99215, assuming the documentation between the two physician services support the higher level of service. Combine the E/M components of both visits and bill the E/M code that best represents the combined service. This must be carefully documented, however. If most of the visit was spent in counseling and/or coordinating care for the patient, it may be better to report the combined time of both services to justify a higher level of service.

Since Mrs. Johnson’s tinnitus could have been addressed in the first office visit, there is really no justifiable medical necessity for two office visits. But had Mrs. Johnson fallen and fractured her nose around lunch time and came to the office for the nasal fracture in the afternoon, the practice should be able to support the second E/M service to most payers.

Important: Private payers may follow this rule, or might make their own payment guidelines. It is always safer to be aware of payer specific guidelines on this and make your physician aware of this.

Game changer: Coding rules shift if Mrs. Johnson comes to your office twice in the same day and sees different physicians in different specialties. In that case, you could submit two separate claims for the services.