Primary Care Coding Alert

Question: A patient sees one physician in the practice and is unhappy with that provider. He demands to see another physician, who injects his shoulder. How should we bill this visit(s)?

Texas Subscriber

Answer: A payer may not reimburse for two visits on the same day, especially with the same diagnosis. It depends on what the first physician did during his or her time with the patient. If the physician took a history, performed an exam and made a decision about the type of problem and treatment the patient required, you could bill a low-level E/M visit, such as 99213 (Office or other outpatient visit for the E/M of an established patient ...)

But if the second physician documented a review of the first physicians history, performed an examination and made a medical decision that the patients problem required treatment the injection this is probably the visit that should be submitted for reimbursement. The majority of payers are only going to reimburse for one visit on the same patient submitted by the group. If the patient was upset enough to demand to see another physician and receives an explanation of benefits that shows billing for both physicians, you would now have a very angry patient who may choose to complain to the payer that he/she never really received any treatment from the first physician.

In any case, you may also be able to bill for the injection of the shoulder. For example, you can bill 20610* (Arthro-centesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) in addition to the E/M code, depending on the injection administered. If so, attach modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code to indicate that it was significant and separately identifiable from the injection procedure.