Part B Insider (Multispecialty) Coding Alert

Published on Thu Sep 15, 2005 PDF

But be prepared to fight for your reimbursement

If your patients love you so much they keep coming back for more during the day, you can receive more payments from Medicare …quot; but you’ll have to work hard for the money.
Myth: Many coders believe that you can’t bill Medicare for more than one evaluation and management visit on the same day, and that you should combine the two visits into one. This is true in the hospital, but not in the office, say experts.
Reality: What is true is that billing multiple E/Ms on the same day is an uphill battle and may not be worth the trouble, experts caution.
The Medicare Claims Processing Manual specifically states that Medicare won’t pay for two office visits by the same physician for the same patient on the same day unless they’re for unrelated problems, experts note. And Part B carrier TrailBlazer Health Enterprises recommended in its March 2000 bulletin that you use the 76 modifier (Repeat procedure, same physician) when billing a second E/M on the same day. Other sources recommend using the 59 modifier (Distinct procedural service).
Hazard: Chances are, your carrier will deny claims for two E/M visits on the same day, says Phyllis Klein, president of PK Administrative Services in Englewood, CO. Unless the physician needs to use a critical care code in the office, or a prolonged care code, in addition to the E/M code, the carrier probably won’t know what to make of it, Klein warns.
“You’re going to have to send documentation, you’re going to have your payments delayed, and the patient’s going to have two copayments,” warns Barb Pierce with Professional Management Midwest in Omaha, NE. In the end, the reimbursement will be higher than for one E/M service, but it will be hard-won money.
If the patient comes back the same day with an exacerbation of the same problem, you should definitely combine the two visits, and you can probably claim a higher level service because of the added history and decision-making, Pierce advises.
But in at least one case where an exacerbation later in the day was serious enough, Wenatchee Valley Medical Center has been able to convince the payor to reimburse both E/M services separately, reports Connie Stevens, compliance officer and reimbursement manager. “It’s not a hard and fast rule that you can’t bill two visits in one day when you’ve got appropriate documentation to support why.”
Bottom line: If you do combine two visits into one, don’t raise the level of the combined visit to a level five, or the carrier will most likely downcode it, warns JoAnn Baker with Precision Coding & Compliance in Hackettstown, NJ. Be sure to mention any comorbidities or exacerbations in the patient’s condition to help justify the higher level, she adds.