Billing same E&M code and DX on same day appropriate with Mod 25?

jmad456

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Is it ever appropriate for a provider to bill 2 different claims for the same patient, same DOS with the same E&M when the only difference is a modifier 25? For example 99213 on one and 9921325 on the other both have same DX.

The mod 25 guidelines aren't clear on this to me but I would think that a higher level E&M code would be used instead of 2.

I see this a lot where I work and most of the times one is a corrected claim but if they aren't marked corrected both will automatically pay.
 

thomas7331

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Most payers I've worked with, Medicare included, have specific policies that state that a second E&M on the same date by the same provider and specialty would only be paid if it was for a different problem that could not have been addressed at the first visit. Even then, these are usually only paid after an appeal. Standard coding practice is to combine E&M services performed on the same date into a single code that captures all of the services. If you are seeing payment in this situation, I think it's most likely a system or processor error on the payer side and there's a good chance that the payment will be recovered retrospectively during audits.
 

Orthocoderpgu

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Only one E/M would be reported per day. Even if the same patient were seen twice for different medical conditions. You would add up the Key Components for both visits and bill one E/M.

If it has not happened yet, at some point the insurance will note that there are two office visits are for the same date, and they will take their money back.
 
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