Medicare Compliance & Reimbursement

Question: We had a patient come into our emergency department (ED) then leave after seeing the physician. She came back a few hours later for a second ED visit that was connected to the original complaint. How do we code for two visits on the same day that are related?

Texas Subscriber

Answer: Although it’s tempting to report two different codes for the separate ED services, that’s not always the best approach. Some payers will not reimburse you for two related E/M visits on the same date of service. Your first step when making the determination of how to code will depend on whether the first and second visits were related to one another.

Example: For instance, suppose a patient who is on blood thinners presents in the morning with a severe nosebleed. The doctor performs the appropriate history and physical examination and packs the patient’s nose. The bleeding stops and the doctor discharges the patient. Later that day, the patient returns with increased bleeding. Again, the ED physician performs the relevant history, exam, and lab work. They then repack the patient’s nose.

If you’re billing Medicare, you shouldn’t report two visits for this patient, because the chief complaint was the same both times. Unless the visits are completely unrelated, Medicare prefers that you combine them into one E/M service, using the most appropriate code from the 99281-99285 range.

Additionally in this case, you could report the repeat nasal packing procedure separately with code 30901 (Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method) or 30903 (Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method). Depending on whether the same physician provided each treatment, you would append either modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) or modifier 77 (Repeat procedure by another physician or other qualified health care professional). Of note, physicians of the same specialty in the same group are “deemed” to be the same provider according to CPT^®.

If the visits are for the same reason and the same provider (or another ED provider from the same group practice) performs both, then you’ll typically roll the documentation for both visits into one ED code for the combined visits.

In other cases, you may be seeing patients for two different problems, and some payers will reimburse you separately for both visits in this scenario. For example, if a patient presents in the morning after falling off a stepstool and breaking her leg and then comes back again in the afternoon with chest pain, you may be able to collect for both.

The Medicare Claims Processing Manual states in chapter 12, “The Medicare Administrative Contractors (MACs) may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office, off campus-outpatient hospital, or on campus-outpatient hospital setting which could not be provided during the same encounter.”