Medicare Compliance & Reimbursement

Reduce wasted time and resources with these expert tips.

You know that if two physicians share the same tax ID, you have to be careful not to bill two separate codes for the same-patient, same-day services. Learn when you should bundle separate E/M encounters, when you can afford to bill for a higher paying E/M code, and under which circumstances you should add a modifier.

Take a look at this case study to learn the rules for billing separate E/M encounters.

Review the Case

Scenario: Two internists in the same practice treat an asthma patient twice on the same day. In the morning, physician A prescribes new asthma medication for a patient who’s been having occasional attacks and codes the encounter as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).

Later that day, the patient returns wheezing and sees physician B, who performs and documents 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…Typically, 25 minutes are spent face-to-face with the patient and/or family) with a nebulizer treatment.

Can you bill both 99213 and 99214 on the same date of service for both of these encounters? Read on to test your answer against the experts’ advice.

Same Specialty Equals 1 Code

In this scenario, you have two physicians in the same group who are not in separate specialties (both are internists in the same group). Both doctors see the same patient in the office on the same day. You cannot bill two separate codes for the same-patient, same-day services.

Here’s why: Payers often consider working together as partners in the same practice and same specialty as one billing person. Even though the physicians have different NPI numbers, both bill under the practice’s tax ID number. Some payers to which you bill services on the same day but at different times will reimburse based on the date of service not on the time of day the service was performed on the same day. That means that the payer would consider the same-day services bundled (whether two E/Ms or an E/M and a procedure).

“If anyone’s tried to bill the two E/Ms on the same day by the same provider, or same specialty provider in the same specialty group, they know it’s just not going to get paid unless the doctor proves in their documentation that these are two distinct problems,” says Kris Cuddy, CPC, CIMC, Healthcare Compliance Analyst at Michigan State University HealthTeam in East Lansing, Mich.

You would normally combine both E/M services into one code. CPT^® considers an E/M service’s history and physical global for the day. Therefore, correct billing bundles same-day office visits together.

Official guidance: According to MLN Matters article MM4032, “Carriers 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 or outpatient setting which could not be provided during the same encounter (e.g., office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident).” You can read this article at www.cms.gov/mlnmattersarticles/downloads/MM4032.pdf.

Better way: Combine the two physicians’ work and submit one E/M code, such as 99215 (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 comprehensive history; A comprehensive examination; Medical decision making of high complexity… Typically, 40 minutes are spent face-to-face with the patient and/or family.) This combines the E/M components of both visits and allows you to bill the higher E/M code. This must be carefully documented, however.

“It would behoove the physicians to combine their documentation and either bill a higher level E/M service for the total E/M services provided (and the practice would determine how to split reimbursement if that were an issue), or to look at the prolonged service codes (remembering it needs to be the physician face-to-face time with the patient that counts towards those codes),” Cuddy advises.

You should also report physician’s B procedures, such as 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]).

Caveat: If the second provider “only provided nebulizer treatment and did not perform a separate exam and medical decision making to determine the nebulizer treatment was necessary, then there is no medical necessity to support E/M 99214,” warns Catherine Brink, BS, CMM, CPC, CMSCS, president of NJ-based Healthcare Resource Management. “If 99214 was indeed performed and documented, then the 25 modifier is needed.”

Beware Private Payer Differences

Private payers may follow this rule or might make their own payment guidelines. It is always safer to be aware of payer specific guidelines on this and make your physician aware of this.

Some private payers may pay for the second E/M visit, billed with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when linked to a separate, distinct diagnosis.

Different Groups Changes Billing

For the scenario above, both internists work for the same group practice. But what if you bill for one practice and the scenario changed so that physician A is part of your practice and physician B is part of another practice, such as an urgent care group?

If the internists are in two different groups (not covering for each other), they should each bill the appropriate E/M service code: 99213 for physician A and 99214 for physician B. “In the case where it’s two different doctors’ offices, and not within the same group (or same specialty in the corporation), then both services may be billed and receive payment,” Cuddy explains.

Caveat: Payers may require different ICD-9 diagnoses, such as controlled extrinsic asthma (493.01, Extrinsic asthma; with status asthmaticus) and exacerbated asthma (493.02, Extrinsic asthma; with [acute] exacerbation) for payment. “Needless to say the medical necessity (diagnosis) will determine the need for the patient to see two different specialists from two separate practices,” Brink explains.

Alter Billing for Different Specialists

If the scenario above changes so that physician A and physician B are in different specialties, the billing changes yet again. In this case, you should be able to bill both E/M codes. If two physicians in the same multispecialty group with different specialties, such as neurology and cardiology, see a patient on the same day for diagnosis and/or treatment of different conditions, you should be compensated for both services. Support the codes with the (presumably) different diagnosis codes you’ll report.

“If the physicians have different taxonomy numbers, proving the different specialties, you should be able to bill the two different doctors/two different specialties,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPCH, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

Example: A patient sees her primary care provider, a family practitioner, in your group practice for lumbar instability (724.8, Other symptoms referable to back) and low back pain (724.2, Lumbago) after a fall V15.88 (History of fall) and then sees one of your neurologists for assessment of possible cubital tunnel syndrome. Since the physicians have different specialties, you may report both services. Assign a diagnosis code for the neurologist’s service based on what the physician finds or the patient’s signs and symptoms if no definitive diagnosis is established — for instance, 354.2 (Lesion of ulnar nerve) or 782.0 (Disturbance of skin sensation).

Heads up: Your payers might reimburse on only one of the E/M services because their claims processing software doesn’t have the capability to recognize the providers’ different specialties. Appeal the denial with documentation for both providers’ services, showing that two different specialties performed the services for different medical conditions, and explain the difference in the physicians’ expertise.

“The payer may deny one of them and if so, you will need to appeal and show the different specialties, separate services, the different specialties, and the different taxonomy numbers,” Cobuzzi agrees.