Wiki 25 vs 27

[Morris73]

For ER visits, two in the same day, which would be more appropriate?

 

[LouiseR1]

Ive always used modifier 25 .. .It was my understanding that 27 is only used for Ambulatory Surgical centers...if its an ER visit then that would be a hospital setting...

If anyone knows different I would be interested as well

thanks,
Louise

 

[mitchellde]

27 is for hospital outpatient use, for the facility coder not the physician. The physician cannot bill two visit on the same day the facility can. If the facility has 2 ER encounters for the same patient, same day, then they would append the 27 modifier to the second visit. If a procedure is performed at either encounter then both visits will need a 25 and the second will also have the 27 like this
rev center visit level procedure
450 99283 - 25
450 99284 - 25 27 20553
also the claim requires a G0 condition code.

 

[LouiseR1]

I have been paid before for two ER visits when billing with modifier 25. I do however send in documentation justifying the seperate ER visits...this is the only scenario however when I bill two visits in one day....

thanks,
Louise

 

[Morris73]

So you are saying that if a pt returns to see the same doc in the er, the facility can bill for both visits, but what would the physician bill for?

 

[mitchellde]

The physician charges one visit which is the compilation of both. The facility may charge for every encounter separate. The facility may charge multiple E&M on the same day if the patient is seen in different clinics such as the er then derm then cardiology and so on

 

[creinhardt]

The question does not address whether or not this is for the facility charge or the physician's fees. When looking at the physician's services, it is proper to bill for two separate encounters as two were rendered. Looking at the CPT code descriptors, an E/R service is biled 9928X and is for Emergency Dept. visit,...which requires these 3 components. It does not state it is a "per day" service. Only the Initial and subsequent observation or hospital care codes, CPT 9922X, are defined as "per day." Now, getting both paid may be an adventure. Your documentation of separate encounters, time of day, reason for service, etc. will be very important, as it will likely require filling an appeal.

 

[kevbshields]

The very nature of professional services dictates that you report only a single E/M per day (with exceptions granted for prolonged service and a few others). If the physicians are in the same practice, same speciality, they may only generate a single E/M per day. Too, the 9928X series can be used and paid by only a single provider per DOS, at least according to most insurance carriers. This would preclude it being used twice by the same specialty or different specialties for that same date.

Hospitals, on the other hand, can report as many clinic visits as occurred per day.