Wiki 2 seperate, significant E/M same day, same doctor

[BonnieJ123]

If a patient comes in to see doctor same day for two seperate reasons, are these billable or considered double dipping? Example:Had auto accident and this is back related and was seen for other aches and pains that pt has had for months that are not auto related and in a different area of the body. Doctor has been instructed to fill out two seperate progress notes for each seperate complaint. Of course, the auto related back injury would be filed to auto and the non-auto would be filed to the patients health insurance. I have instruced the doctor to make sure each seperate E/M meet guidelines for billing that level of service. Please advise.

 

[amartin8]

The only time I have ever had to use two office visits on the same day was when a patient was in to be seen in the morning for an illness, then later on that day had to return to the office for a completely different visit for an injury that happened after the first visit that morning, so there were two separate work ups and completely different diagnosis codes used (I also sent office notes) but I don't think you can do two different E/M for one visit even though there were different diagnoses, I would just use 99215 probably ?? Hope this helps!

 

[JMeggett]

Actually Bonnie, you advised your Provider correctly. The two separate dictated notes is the correct way to go about this. One will be filed to the Auto insurance and the other to the medical insurance. This is correct per CPT and we've done this many times and they are paid. Now if the two issues were going to the same insurance carrier, then you add the level of service from both visits on same day and come up with the highest E&M that's appropriate. Nice job!
Jenna