Primary Care Coding Alert

Question: A physician (on call for medical group) renders subsequent hospital visit services to a patient during regular hospital rounds. Later in the day, after hours, the patients primary care physician is summoned to the hospital due to a patients septic condition. Since Medicare doesnt allow two visits on the same day by a provider of the same group/specialty, how can both physicians get paid for their services?

Anonymous TN Subscriber

Answer: If the two physicians are not part of the same practice, they can both code for the care they rendered, says Kent Moore, manager of reimbursement issues for the American Academy of Family Physicians (AAFP). Depending on how serious the care, the two physicians could code 99231-99233 (subsequent hospital care, per day, for the evaluation and treatment of a patient which requires at least two of these three key components, ranging from problem-focused to a detailed interval history; a problem-focused to a detailed examination; and a straightforward medical decision to one of high complexity).

But if the physicians are part of the same medical practice, they can use only one code for both services. For instance, says A. Peter Catinella, MD, associate professor and vice chairman at the department of family and preventive medicine, University of Utah at Salt Lake City, if the first physician provided 15 minutes of service, he would code 99231.

But if the second physician offers an additional 20 minutes of care, the final submission can be upcoded to 99233 (subsequent hospital care in which the patient is usually unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patients hospital floor or unit). Catinella reminds coders that documentation is crutial.

If the patients condition has turned critical by the time the second family physician provides care, he or she could code 99291 (critical care, evaluation and management of the unstable critically ill or unstable critically injured patient, first 30 to 74 minutes), in addition to the first physicians appropriate E/M coderegardless if they are in the same or different practices as long as the services provided by each doctor are distinct and documented.

If the second physician spends more than 74 minutes with the critically ill patient, he may code 99292, which signifies each additional 30 minutes. Catinella warns coders, however, that most carriers will not honor two E/M codes from the two attending family doctors in the same practice.