E/M Question

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Our Dr sent a patient to the ER from our clinic and one of our staff doctors at the hospital that day saw the patient in the ER. Medicare is denying the second visit [1st visit Outpatient place of service Office - 2nd visit Inpatient place of service Hospital] stating cannot bill two consults in one day. Anyone know of a correct modifier we can use for 2nd visit to be paid?
 

jluvl88

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Was this billed as a consult to Medicare Part B? Part B will deny consult codes, you must use 99201-99205 (new) or 99211-99214 (established). Since this is a different physician in a different location under a different tax ID the claim should pay. If not, append modifier 25 to the EM code. Hope this helps.

If you are billing under the same tax ID and the doctors share the same taxonomy, the claim might not be billable. Try modifier 25 anyway.

Let me know how this works out for you, please. We are breaking ground a new hospital and our practice will physicians on staff there.
 
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Yes, it is same taxID same group NPI, we were thinking the modifier 25 might work - we will try a correction to claim and see if it will pay - Unusual circumstance, it doesn't happen often... Thank you!
 

eurovw

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Yes, it is same taxID same group NPI, we were thinking the modifier 25 might work - we will try a correction to claim and see if it will pay - Unusual circumstance, it doesn't happen often... Thank you!
per rules, any services performed on the same date, when related to the admission, should be included in the initial hospital care code and are not reported separately. This includes office visits, observation visits, and nursing facility visits if provided by the same provider on the same date of service. since the tax id and npi are the same, does it count as the same provider?
 
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per rules, any services performed on the same date, when related to the admission, should be included in the initial hospital care code and are not reported separately. This includes office visits, observation visits, and nursing facility visits if provided by the same provider on the same date of service. since the tax id and npi are the same, does it count as the same provider?
I agree
 

jdibble

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Was this billed as a consult to Medicare Part B? Part B will deny consult codes, you must use 99201-99205 (new) or 99211-99214 (established). Since this is a different physician in a different location under a different tax ID the claim should pay. If not, append modifier 25 to the EM code. Hope this helps.

If you are billing under the same tax ID and the doctors share the same taxonomy, the claim might not be billable. Try modifier 25 anyway.

Let me know how this works out for you, please. We are breaking ground a new hospital and our practice will physicians on staff there.
You cannot use the 25 modifier in this case. Guidelines tell you that if a patient is seen in the office and then seen in the hospital as inpatient on the same day you only bill the inpatient E/M - all other work is combined with that visit. Even if they see a different provider than seen in the office, as long as they are all billed under the same tax id/NPI they are considered as the same provider. Only one visit can be billed per day and adding the 25 modifier would not be appropriate or ethical.

I work for a physician group that is part of a hospital system here in Florida and we would not bill for both E/M visits.
 
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devine1

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Modifier 78 and billing for an E/M code

I have read that the 78 modifier does not restart the global period. However, I am receiving denials for these visits stating that they are within the global period, but the original procedure is out of the global period.

Example, patient had a procedure on 12-11-16 and it is a 90 day global.

Patient returned to the OR on 3-9-17 and we used the modifier 78 since it was a complication from the initial surgery.

Patient then came in for follow up visit on 3-27-17 and the insurance is denying the visit as within the post op global.

Any ideas on how to get paid for these follow up E/M's or are they global?
 

amaher21

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Toms River, New Jersey
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2 office visits same date of service

Looking for any input

pt saw 2 doctors in our practice, same specialty billing out under the same TIN but being treated for 2 different problems - any advise on how to bill out or if it should be billed out?
Thankyou

AM PSC
 

thomas7331

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Looking for any input

pt saw 2 doctors in our practice, same specialty billing out under the same TIN but being treated for 2 different problems - any advise on how to bill out or if it should be billed out?
Thankyou

AM PSC
Most payers have policies that address this situation and will reimburse both visits if the two are completely unrelated and both medically necessary - I would suggest checking your payer's policy for guidelines as to how they want the claim to be submitted. However, I would imagine that it's very likely that the second visit will be denied initially and that you will need to go through some review or appeal process in order to get payment
 
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