Pulmonology Coding Alert

Question: A patient was seen for an office visit (99214). Later on the same day she went to the hospital emergency room and was seen again by the same physician (99284), then discharged home. Would both visits be payable by Medicare?

Arizona Subscriber

Answer: The answer depends on how the emergency room visit came about.

If the doctor says during the office visit that the patient should go to the ER and that he will see the patient later that day in the ER, then you should combine the work of the two services and report just one code - 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: A detailed history; A detailed examination; Medical decision making of moderate complexity...) in this case.

However, if the services were truly unrelated encounters, you can report 99214 and then the appropriate ER E/M code, such as 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity...). You will need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99214. Both services need to be medically necessary/relevant and thoroughly documented. Being unrelated, they should have different primary diagnosis codes listed on the claim form.