Wiki 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.
 
Can you give an example of where you would see the patient twice on the same day for the same dx?
 
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.
 
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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