Pulmonology Coding Alert

Question: Two pulmonologists in our practice treated a patient twice on the same day. In the morning, physician A prescribed new medication for a patient who’s been having occasional breathing problems and coded the encounter as 99213. Later that day, the patient returned with similar complaints and saw physician B, who performed and documented 99214. Can I bill both 99213 and 99214 on the same date of service for both of these encounters?

New Jersey Subscriber

Answer: In this scenario, you have two physicians in the same group who are not in separate specialties (both are pulmonologists in the same group). Both doctors see the same patient in the office on the same day. You cannot bill two separate codes 99213 or 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:…) 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. It does not matter how many times the service was provided on the same day. That means that the payer would consider the same-day services bundled together.

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, it’s not going to get paid unless the doctor proves in their documentation that these are two distinct problems. You would normally combine both E/M services into one code reported under one physician.  It is up to the providers to determine which one will submit the claim for the combined services. 

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 headache 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. Combine the E/M components of both visits and bill the E/M code that best represents the combined service. This must be carefully documented, however. If most of the visit was spent in counseling and/or coordinating care for the patient, it may be better to report the combined time of both services to justify a higher level of service.

Important: 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.