Primary Care Coding Alert

Question: Can we bill two office visits on the same day? We reported 99214 twice for the same date of service but used different diagnoses and insurance paid one and denied the other.

Tennessee Subscriber

Answer: It depends on what the diagnoses were, but most insurers will not allow you to report two office visits on the same date. These payers base their regulations on Medicare rules, which generally prohibit you from billing these together.

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 leg pain following an accident)." You can read this article at www.cms.gov/mlnmattersarticles/downloads/MM4032.pdf.

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

Some private payers may pay for the second E/M visit, billed with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when linked to a separate, distinct diagnosis. Even in this situation, you may need to provide some documentation or explanation to make it clear why the services were distinct and could not be reported as a single encounter (e.g. because of a time lag between the visits, as in the Medicare text above).

Alternately, it would be appropriate to combine the E/M components of both visits and report a single E/M code that reflects the sum of the work done for the patient. This must be carefully documented.