Pain Management Coding Alert

Reader Question:

Heed This ED/Office Visit Advice

Published on Fri Jan 10, 2020

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

North Carolina Subscriber

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

If the physician says during the office visit that the patient should go to the ED and that they will see the patient later that day in the ED, 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, you can report 99214 and then the appropriate ED 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) to 99214. Both services need to be medically necessary/relevant and thoroughly documented. And remember that if an ED physician sees the patient first, the regular physician will bill an outpatient visit code only.