Pulmonology Coding Alert

Question: If a patient was seen for an office visit (99214) first and then later on the same day went to the hospital emergency room and was seen again by the same physician (99284), would both visits be payable by Medicare?

Arizona Subscriber

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

If the doctor says during the office visit that the patient should go to the ER, then you should combine the work of the two services and report just one code — the 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 separate encounters for unrelated problems and the physician also saw the patient in both the office and the emergency department providing independent evaluations and management of the patient’s issues in each setting, 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). Both services need to be medically necessary/relevant and thoroughly documented.  It is likely that one service will be paid, and the other service will be denied or pended for review of documentation.  In this case, you will need to send both notes to demonstrate the unrelated circumstances. Payers may still deny the second service if they limit visits to one per day per specialty, regardless of the circumstances.