Pain Management Coding Alert

Published on Tue Sep 01, 2015 PDF

Question: Our practice has multiple specialties, including orthopedics, pain management, neurology, pathology, radiology, and internal medicine. Some of our patients visit more than one specialist on a given day, seeing, for example, the internist and then the pain management specialist. Is there a limit to the number of times a day I can use an E/M code such as 99212?

Minnesota Subscriber

Answer: If the clinical scenario warrants separate reporting, there is no limit, per se, on the number of times you can report problem-oriented E/M codes, such as 99212 (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 problem focused history; a problem focused examination; straightforward medical decision making…), in one day, as long as they providers are of different specialties (not sub-specialists within the same specialty). Make certain the documentation clearly illustrates the different diagnoses, situations, complexities, etc. You may also want to tell your patients that they will be charged multiple co-pays/co-insurance for the additional visits.

Here’s why: If the physicians are in the same group practice but are in different specialties, and they see the patient for two separate problems, you can bill 99212 (or another appropriate E/M code) twice if that documentation supports that code.

Beware: According to Medicare, if a patient sees multiple physicians in the same practice in the same specialty on the same date, you need to bill as if they were one physician. That means you can only report one E/M service when there is more than one service on the same date with multiple physicians of the same specialty in the same group.

Read more: For more information, refer to 30.6.5 in the Medicare Claims Processing Manual and visit www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf