Practice Management Alert

Look for Changes in Same-Day E/M Rules

Billers who work in larger medical practices that employ more than one kind of physician should pay attention to a recent clarification on Medicare billing.

In transmittal 731, CMS reported that it won't pay for any evaluation and management (E/M) services provided on the same day by physicians in the same practice and same specialty--unless the visits were for unrelated problems.

Sometimes carriers won't pay for same-day E/Ms even when they-re for unrelated problems, but CMS has instructed carriers to pay for repeat visits if they meet certain guidelines.

In a nutshell: If your doctor sees the patient in the office and again in the ED on the same day, or sees a patient in the office and then performs an initial hospital service, Medicare will only pay for one E/M code unless you can prove the visits are for two different problems, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions in Tinton Falls, N.J., and member of the National Advisory Board of the American Academy of Professional Coders.

CMS issued this clarification to prevent -abuse by physician groups in which members sub-specialize,- says Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and president of the AAPC National Advisory Board.

For example, a patient visits a radiation oncology practice to discuss his prostate cancer, but he  meets first with the physician who sub-specializes in brain tumors because he is the only oncologist available. Later that day, he meets with the prostate cancer oncologist.

-Generally, this radiation oncologist will discuss treatment options but also recommend that the patient discuss his condition with the member of the group that specializes in prostate treatment,- Parman says. CMS- clarification means that you can only report a single E/M code in this scenario.
 
-Sudden Onset- of Condition Might Justify 2 E/Ms

You may also bill for two E/Ms in the same day if the patient has a -sudden onset- of a condition. Consider this example, courtesy of Parman:

An established patient scheduled one appointment for digestive pain, and a second for chest pain. -The symptoms may appear to be close, but they generated two visits. It would stand to reason that the second visit could be a -sudden onset- of a condition not present during the first encounter,- Parman says.