Pulmonology Coding Alert

Question: We have a patient who saw the pulmonologist in the morning then came to our after-hours clinic that same evening with the same symptoms but saw a different pulmonary physician. Should I bill for both visits? Both physicians are in the same group but at different locations.

Maine Subscriber

Answer: Billing for two office visits on the same day by two members of the same group may be challenging. Medicare states that this situation is allowable when the patient is being seen for two different reasons. In other words, the reason for the second visit is unrelated to the reason for the first visit. A clear example of this is when the patient comes to the office in the morning for an evaluation of chronic obstructive pulmonary disease (COPD, 496) and has to return later in the day to be evaluated for painful respiration (786.52).

Not so clear is when the patient comes into the office in the morning for shortness of breath (786.05). After evaluating the patient, the pulmonologist attributes the patient's symptom to an acute exacerbation of asthma (493.92) and adjusts the patient's medication. Later that same day, the patient returns for an evaluation of increased shortness of breath. The physician evaluates the patient and, due to the nature of the developing cough and fever, determines that the patient has pneumonia (486).

Although the presenting symptoms (shortness of breath) are the same for both visits, the diagnosis and treatment plan are quite different. Both of these services should be billed under the appropriate physician's name. The first visit should be reported as 9921x (Office or other outpatient visit for the evaluation and management of an established patient ) with the diagnosis code for asthma with acute exacerbation (493.92) as the primary diagnosis and shortness of breath (786.05) as the secondary diagnosis. The second visit should be billed as 9921x with pneumonia as the primary diagnosis. You may also choose to include shortness of breath as a secondary diagnosis for the second visit, but this could be confusing to the insurer because it could perceive this as duplication of services, i.e., seen twice for the same or a related condition.

Because the physicians are in the same group, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the second visit code to alert the insurer of the modifying circumstances. Otherwise, the payer may think it is a duplicate claim.

Be prepared to provide the supporting documentation in case your claim is questioned or denied. Non-Medicare insurers may pay for only one E/M service per day per group regardless of the reason for the visits as outlined in their contracts.