Billing Two Visits From Same Date to Medicare (FQHC)

rsager1985

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I work for an FQHC and we've never been able to get Medicare to send two payments for the same date of service for the same patient. We're not trying to double dip, it's just that some of our patients will sometimes see two different providers at our clinic on the same day (vision/medical, or mental health/medical).

According to MLN Matters Article SE1039, "Effective January 1, 2011, two services lines are submitted with a 052X revenue code and one line contains modifier 59. Modifier 59 signifies that the conditions being treated are totally unrelated and services are provided at separate times of the day, e.g., treatment for an ear infection in the morning and treatment for injury to a limb in the afternoon." I interpreted this as meaning that we have to put a modifier 59 on one of the E/M codes to get Medicare to pay additional money for the second visit. I've tried this on dozens of claims, and they've all rejected as duplicate claims. I've called our contractor (Novitas Solutions) and they had the claims reprocessed many times, only for them to reject again and again for the same reason.

According to MLN Matters Article MM8863, the XE modifier can be used to indicate "A Service That Is Distinct Because It Occurred During A Separate Encounter." I've tried using the XE modifier to no avail.

Has anyone else had this same issue? Is it possible to get two payments when multiple encounters occur on the same date of service?
 

ellzeycoding

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Established patient E/Ms 99212-99214 have an MUE of 2 interestingly enough.

If a patient is seen twice on the same day (separatate enocunters) by the same provider for 2 unrelated issues that both generate an E/M, you can technially bill 2 established E/M visits.

You can also bill 2 E/M visits on the same day if the specialty codes for multiple proviers are different.

CMS has provided a source of specialty codes and taxonomy codes

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/JSMTDL-08515MedicarProviderTypetoHCPTaxonomy.pdf
 

rsager1985

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Robert,

Please refer to this link: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c13.pdf. Section 40.3 refers to billing multiple visits on the same day. In most cases you cannot bill for multiple visits on the same day.

Heather
Yes, I have referred to that section in the past. I posted the link to the MLN article that covers the exact same subject, using modifier 59 to bill multiple visits. This has never worked, Medicare doesn't seem like they understand their own policies.
 

rsager1985

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Established patient E/Ms 99212-99214 have an MUE of 2 interestingly enough.

If a patient is seen twice on the same day (separatate enocunters) by the same provider for 2 unrelated issues that both generate an E/M, you can technially bill 2 established E/M visits.

You can also bill 2 E/M visits on the same day if the specialty codes for multiple proviers are different.

CMS has provided a source of specialty codes and taxonomy codes

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/JSMTDL-08515MedicarProviderTypetoHCPTaxonomy.pdf
If the patient is seen twice by two different physicians at the same FQHC, and we are billing two facility claims, does that still count as two different providers?
 

rsager1985

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hperry10

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Established patient E/Ms 99212-99214 have an MUE of 2 interestingly enough.

If a patient is seen twice on the same day (separatate enocunters) by the same provider for 2 unrelated issues that both generate an E/M, you can technially bill 2 established E/M visits.

You can also bill 2 E/M visits on the same day if the specialty codes for multiple proviers are different.

CMS has provided a source of specialty codes and taxonomy codes

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/JSMTDL-08515MedicarProviderTypetoHCPTaxonomy.pdf
The difference for an FQHC is that we can only bill 2 encounters on the same day if there is a qualifying medical visit and a qualifying behavioral health visit or if the patient is seen for a med visit and has to return because they were injured or had fallen ill since the earlier visit. For example if a patient is seen by their doctor for a follow up on HTN and then had an appt with our dermatologist later in the day, we only get paid for one visit. The rules for PPS are very specific. Also, if you do have 2 qualifying visits they have to be submitted on the same claim. They will deny as duplicates if they go out on separate claims.
 
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rsager1985

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The difference for an FQHC is that we can only bill 2 encounters on the same day if there is a qualifying medical visit and a qualifying behavioral health visit
How do you do that? Every time I bill one claim for medical services and another for mental health, one gets paid and the other gets rejected as a duplicate. I've tried modifier 59, condition code G0, modifier XE, and nothing works.
 

hperry10

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How do you do that? Every time I bill one claim for medical services and another for mental health, one gets paid and the other gets rejected as a duplicate. I've tried modifier 59, condition code G0, modifier XE, and nothing works.
Are you submitting them on the same claim? I am looking at one of the patients I do this for on a regular basis. She is seen by one of our doctors and a therapist at a nursing home. I billed the following codes: 99308, G0467, 90834, G0470 with no modifiers on the same claim - not separate claims and was paid by Medicare by both visits.
 
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mitchellde

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I am a little confused, you are not billing for the provider , you said you are billing for the facility, so you are a facility with outpatient areas? the provider sees the patient and bills their service and then you bill for the facility outpatient area? I still think the 27 if that is the case. If you are trying to bill two physician claims for the same day then there is no modifier or mechanism to be able to do that.
 

rsager1985

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Are you submitting them on the same claim? I am looking at one of the patients I do this for on a regular basis. She is seen by one of our doctors and a therapist at a nursing home. I billed the following codes: 99308, G0467, 90834, G0470 with no modifiers on the same claim - not separate claims and was paid by Medicare by both visits.
I've done that, but we don't receive any additional money, we receive one payment for both encounters. The end result is exactly the same as Medicare paying for one encounter and denying the other. There is no difference in terms of actual dollars received.

mitchellde
I am a little confused, you are not billing for the provider , you said you are billing for the facility, so you are a facility with outpatient areas? the provider sees the patient and bills their service and then you bill for the facility outpatient area? I still think the 27 if that is the case. If you are trying to bill two physician claims for the same day then there is no modifier or mechanism to be able to do that.
We are an FQHC, not a hospital. We bill almost all of our services on a UB-04 to our Medicare contractor, with the exception of carve outs, like labs and technical components of diagnostic tests (EKGs, etc). So most of our encounters do not generate provider claims; it depends on what services were rendered. In other words, all of our Medicare claims are facility claims, except for when labs are done, in which case, two claims are generated for the encounter. Our MAC reimburses the facility claims with a flat rate payment, and the professional claims (billed on HCFA 1500s) are reimbursed fee for service.
 

hperry10

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I've done that, but we don't receive any additional money, we receive one payment for both encounters. The end result is exactly the same as Medicare paying for one encounter and denying the other. There is no difference in terms of actual dollars received.


Hmmm..that's interesting. We are not having problems with this. I have run out of suggestions. :confused:
 

thomas7331

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I'm not familiar with FQHC billing rules, but when we billed Medicare for outpatient claims for eligible multiple clinic visits in the hospital where I worked, we were required to submit a G0 condition code on the UB in order to get more than one visit paid - have you tried that?
 

rsager1985

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I'm not familiar with FQHC billing rules, but when we billed Medicare for outpatient claims for eligible multiple clinic visits in the hospital where I worked, we were required to submit a G0 condition code on the UB in order to get more than one visit paid - have you tried that?
Yes, it doesn't work.
 

cjtown

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FQHC PPS rates

Robert,

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-PPS-FAQs.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf.

The above should help with your dilemma.
From FAQ:
Q1. Are there any situations where a FQHC can bill for more than one visit per day for the same patient?
A1. Yes, there are two exceptions. The first exception is when a patient is seen in the FQHC for a medical visit, leaves the FQHC, and subsequently suffers an illness or injury that requires additional diagnosis or treatment on the same day. An example would be if a patient sees a FQHC practitioner in the morning for a medical condition and later in the day has a fall and returns to the FQHC for treatment of their injury.
Q2. Can the FQHC bill for two visits if one visit is medical and the other is mental health?
A2. Yes, this is the second exception. A FQHC can bill for two visits when a patient has a FQHC visit with a mental health practitioner (clinical psychologist or licensed clinical social worker) on the same day as a medical visit with a physician, nurse practitioner (NP), or physician assistant (PA).

Hope this helps.:cool:
Carla Townsend, CPC, CPPM ,CPB, CH-CBS
FQHC Revenue Cycle Manager
 

rsager1985

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Q2. Can the FQHC bill for two visits if one visit is medical and the other is mental health?
A2. Yes, this is the second exception. A FQHC can bill for two visits when a patient has a FQHC visit with a mental health practitioner (clinical psychologist or licensed clinical social worker) on the same day as a medical visit with a physician, nurse practitioner (NP), or physician assistant (PA).
Like I said, every single time I've tried doing this in the past, the second claim has rejected as a duplicate. I've tried billing with modifier 59, modifier XE, condition code G0, and nothing works.
 

boomba003

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A 59 modifier cannot be used on an E/M. This is noted in the CPT Manual in the description of the modifier.
Additionally, modifier 59 is a modifier that is used in the unbundling of a column two code from a column one code.

There are no code pairs of the same CPT code in the NCCI Edits. Using the subset such as XE, XS, XU is the same as using the 59 modifier.

There are two acceptable methods of billing two E/M visits on the same day if these services are billed on the same day for Medicare when the services are billed under a Group Tax ID / NPI and that these services are outpatient.

Method one: If the providers have the same parent taxonomies but different sub-specialties (i.e. Internal Medicine for Dr. A and Internal Medicine with a fellowship in Infectious Disease for Dr. B, a modifier 27 can be used as long the diagnoses are NOT the same or simular.

Method two: Both providers can be billed on the same claim with Dr. A on line one with the E/M and a prolong visit code on line two for Dr. B. (each provider's NPI in Blk 24J). The time requirements for the prolong visit will still have to met and documented (total of time 74 minutes or more).

Most commercial insurances will not accept method one and do not recognize sub-specialties.

Hope this helps

William Klyn, CPC
wklyn@roadrunner.com
 

hperry10

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Like I said, every single time I've tried doing this in the past, the second claim has rejected as a duplicate. I've tried billing with modifier 59, modifier XE, condition code G0, and nothing works.
I know you said that you have called Medicare and they have told you that they cannot tell you how to bill. Have you explained that you are following their rules and that they are not processing it correctly? Sometimes it depends on the rep you talk to. Some reps are unable to go beyond the script they are given. We are having no problem submitting a behavioral health and medical visit on the same claim. Are there other FQHC's in your area that you can reach out to?

Heather
 

rsager1985

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A 59 modifier cannot be used on an E/M. This is noted in the CPT Manual in the description of the modifier.
Additionally, modifier 59 is a modifier that is used in the unbundling of a column two code from a column one code.

There are no code pairs of the same CPT code in the NCCI Edits. Using the subset such as XE, XS, XU is the same as using the 59 modifier.

There are two acceptable methods of billing two E/M visits on the same day if these services are billed on the same day for Medicare when the services are billed under a Group Tax ID / NPI and that these services are outpatient.

Method one: If the providers have the same parent taxonomies but different sub-specialties (i.e. Internal Medicine for Dr. A and Internal Medicine with a fellowship in Infectious Disease for Dr. B, a modifier 27 can be used as long the diagnoses are NOT the same or simular.

Method two: Both providers can be billed on the same claim with Dr. A on line one with the E/M and a prolong visit code on line two for Dr. B. (each provider's NPI in Blk 24J). The time requirements for the prolong visit will still have to met and documented (total of time 74 minutes or more).

Most commercial insurances will not accept method one and do not recognize sub-specialties.

Hope this helps

William Klyn, CPC
wklyn@roadrunner.com
According to this, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1039.pdf , we are supposed to put modifier 59s on E/M codes when there are multiple E/M codes for the same date of service.
 
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LKaf7

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We are a FQHC and do this for our Medical/BH visits, we do use the modifier 59 on the G0467 or G0470 and our claims have been starting to process and we are receiving our rate for both visits.
 
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I'm in the same situation can they be billed on the same claim or do separate claims if possible can you show me an example..





Thank You
 

tammster

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Are you sure that the mental health visit is going out with the correct G code and/or the correct revenue code? Perhaps that is the problem ... if both of the G codes are being reported with 521 - it would deny as duplicate. The mental health visit must have revenue code 900 associated with it.
 

sdb67

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HELP!!! Rural Health Billing both Facility & Profession on Same day

Help! Can someone help me? I have a rural clinic who is billing both facility 99308 and professional 99308 for the same dos. i'm not really familiar with Rural Health Billing
thank you for anyone who can assist me!!!
 
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Inpatient Multiple Visits

We're getting a lot of rejections because we work for a Gastro specialty. Our Gastro Drs are often on call at an inpatient hospital.
This particular hospital will have the admitting provider/hospitalist do a consult first.Then he calls in the specialty Doctors to do further workup.

Case Scenario: Patient gets admitted for Epigastric pain. Hospitalist does a consult and calls Cardio and GI to come in and access the patient for Epigastric pain, as it could be related to GI or Cardiac issues. They all put in the same amount of work and charge the same CPT & DX codes. Insurance kicks it back when they review because it looks like we charged the patient 3 times. However, these are all physicians from different specialties. They are all working under the same Facility NPI, however. Is there any sort of modifier that would help us avoid this?

I read up on Mod 27 but it looks like it's just for Outpatient, and this would be for inpatient. Please help me; I'm not even through with my coding course yet! :confused:
 
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If you have received payment for 1 service, it must be cancelled. Then, it can be re-billed with the 2 visits on the same day.
 

NIKI01

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Hello,

2 Visits on same day for the same problem in ED dept. I am confused when pt. is staying overnight and then is coming back for same problem.
Example: PT. came in on 9/26 at 10:00pm for low back pain. and was discharged on 9/27 at 3:00am. then is coming back on 9/27 at 9:00am for low back pain again and nausea and then is discharged on 9/27 at 1:00pm.
I am assigning 2 facility levels with -27 on second level and I am assigning only 1 profee level on the second visit.
I am discussing this issue with my co-workers and we have a different view on this subject.


I would like to know other coders opinion. What should be taken under consideration admission date or discharge date when coding for 2 visits on same day on same problem?

Thank you so much for any help,
Niki
 

lfoxwell

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Patient comes in for an injection seen by the nurse, then later that day has a virtual visit with the physician. Can you bill for both visits ? My EHR is kicking it out saying you can't ? This is for a commercial Insurance too.

Thank you very much for any help,
Lorrie
 
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