Wiki 99223 denied


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Good morning,

Dr. A reported 99291 & was paid

Dr. B reported 99223 & was not paid.

They both used the same dx.

Medicare is denying 99223 for only one E/M can be paid in one day. Can someone confirm this for me & explain or direct the guidelines?

Thank you!
Are these providers within the same group?? You can bill an initial visit AND critical care for the same day. If it is the same provider/or provider group the 99223 requires a modifier 25.
Actually it depends on the circumstances of the admissions. Assuming these doctors are in the same group practice, if the patient was admitted (99223) prior to receiving critical care services then got worse and required critical care, you can bill both. If the patient received critical services upon presentation to the hospital then only the critical care can be billed. The Medicare claims processing manual is very clear that they will only pay for one E/M per doctor per day except in unusual circumstances.

You should check the sequence of events and then determine if you can appeal based on the documentation
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