Question E&m coding

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Woodbridge, NJ
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Our doctor is a nephrologist, He states he is able to bill 2 E&m codes on the same day. He states we can bill 99291 with 99255 as long there's a modifier on the code. Is this correct ? If so Can you direct me where I can find this information? I was always told by Medicare and other insurances that they will only pay one e&m per day.
 

thomas7331

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Medicare does not recognize 99255 because that is a consultation code, but aside from that, you are allowed to bill critical care and an E&M service on the same date under the following circumstance:

When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical Care Services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service.

You'll find this guidance in the Medicare Claims Processing Manual, Chapter 12, section 30.6.9 A. - Hospital Visit and Critical Care on Same Day, which you can find here:

For non-Medicare insurance plans, you would need to review the policies of the specific payer you are billing.
 

Orthocoderpgu

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Generally speaking you are correct, a physician can only bill one E/M code per day because you take all the services performed that day and add them up to get your E/M level. Code 99291 is for performing critical care, so that is different work than an actual E/M. I also have to point out that this coding combination is so scarce that it would almost never be reported to insurance. I also need to point out that just because your doctor is a specialist and another physician needs your doctor to see a patient, that is not a consult. I know doctors use the term consultation and even coders do as well, but bottom line, unless the three "R"s of a consultation are met, it's not a consultation.
 
Messages
4
Location
Woodbridge, NJ
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Generally speaking you are correct, a physician can only bill one E/M code per day because you take all the services performed that day and add them up to get your E/M level. Code 99291 is for performing critical care, so that is different work than an actual E/M. I also have to point out that this coding combination is so scarce that it would almost never be reported to insurance. I also need to point out that just because your doctor is a specialist and another physician needs your doctor to see a patient, that is not a consult. I know doctors use the term consultation and even coders do as well, but bottom line, unless the three "R"s of a consultation are met, it's not a consultation.
Thank you . I appreciate your help.
 
Messages
4
Location
Woodbridge, NJ
Best answers
0
Medicare does not recognize 99255 because that is a consultation code, but aside from that, you are allowed to bill critical care and an E&M service on the same date under the following circumstance:

When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical Care Services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service.

You'll find this guidance in the Medicare Claims Processing Manual, Chapter 12, section 30.6.9 A. - Hospital Visit and Critical Care on Same Day, which you can find here:

For non-Medicare insurance plans, you would need to review the policies of the specific payer you are billing.
Thank you . This was a great help.
 
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