Modifier for two visits on same day

SoundarR

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Hi,
Im working for NP's , i have a doubt in modifier.. If a patient is visiting two times on same day to different NP for two different reason means which modifier is suitable to bill both? i tried to bill it with 27 for one visit but medicare denies it.If it is same NP means we can use 25, please tell me what modifier for two unrelated visits on same day to two different NP's?

Please help me to sort out this problem...

Thanks,
Soundar
 
First, the 27 modifier is for facility billing only.
Second, if your NPs are in the same specialty, then you will not be successful with trying to bill 2 visits on the same day. If you provide more information I might be able to give more help. Such as are both NOPs in same tax ID, and what was the dx for each encounter, and the need for 2 encounters on the same day.
 
I don't beleive there is a modifier, Medicare should pay both claims as long as there are two different doctors and two non-related diagnoses. I have had Medicare pay for same day claims under these circumstances.
 
If the docs are in the same specialty in the same tax ID, I have never had any payer including Medicare pay for 2 visits even if dx is different. If different tax Id then fine, If different specialty, then fine. I think it depends on what type of circumstances she has.
 
I'm with Debra on this....

Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

30.6.5
 
The reason I ask - in the Medicare E&M Services Part B published Sept 2009, under the heading Physicians in Group Practice..... it states If more than 1 E/M service provided on the same day by the same physician or more than one physician in the same specialty or group for unrelated problems you can use the 76 modifier. Hope this helps
 
I am with Rebecca, Thank You for the reference, I was looking thru my database for the same one you posted. The 76 modifier is not for use on E&Ms and does not make sense, for if the patient returns on the same day for an unrelated issue then it would not be a repeated service. I too would love to be able to see this from CMS.
 
I see where it says it but that is for trailblazer and is not CMS. Also per HIPAA, the codes and modifiers all have the same definitions regardless of the payer. I just cannot see how in any way this fits the definition of the 76 modifier for a repeat procedure/service. Since the dx is different then the same service cannot be repeated. And in the federal register it is stated this modifier is not for E&M codes.
 
Physicians in Group Practice
• Physicians of the same specialty in the same group practice must bill and be paid as a single physician.
• If more than one E/M (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one E/M service may be reported unless the E/M services are for unrelated problems. (Refer to instructions for use of the 76 modifier.)
Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.

• Use the 76 modifier when billing for separate office or outpatient E/M visits that occur on the same date of service (only for codes 99211–99215) by the same physician/practitioner.
• Each service should be clearly documented.
Use the 76 modifier to indicate a separate encounter occurred on the same date of service when separate services are billed. Do not use the 76 modifier for the initial visit.

Example of Proper Usage
A patient visits the physician on Wednesday morning for a bladder infection. She is treated and sent home. That same afternoon, the patient returns to the physician’s office with a twisted ankle. Each service should be reported with the appropriate level of E/M service with the 76 modifier added to the second visit for the twisted ankle.



Talk about speaking out of both sides of the mouth. This is definitely carrier discretion...
 
I understand what you are saying. I have yet to use this modifier in this situation and do not know how it would pay. The publication is by TrailBlazer our FI but based from CMS guidelines. They should not be different.
 
Unfortunately or fortunatley (depending on your view) your MAC can create guidelines applicable to your locality. This can become burdensome when you refer to the CMS manuals for guidance; yet, your local carrier states the complete opposite. That's why...when giving advice...I direct them to CMS guidance but always suggest to contact their local carrier for their view. Here is an example of why this is important to do this...
 
My carrier...

April 15, 2008

Inappropriate Use of Modifiers 76 and 77

We have seen an increase recently in use of the -77 and -76 modifiers with E&M services to bypass edits related to concurrent care by two physicians of the same specialty on the same day. Communication with CMS Central Office has confirmed that this is an inappropriate use of these modifiers. Although the CMS Manual system doesn't clearly state this, per se, the intent is and always has been for these modifiers to apply only to procedures, not to E&M services. Revised language making this clear will be coming out in a Manual revision later this year, and a forthcoming NCCI update will also make this clear. In the meantime, providers are encouraged to not append the 76 and 77 modifiers to claims for E&M services. Future audits of such inappropriate use of the modifiers on claims will likely result in recoupment of monies incorrectly paid.

http://www.cignagovernmentservices.com/partb/pubs/news/2008/0408/cope7413.html
 
Here is something from the AMA 2008 for starters:
Using modifier 76
Modifier 76 (repeat procedure or service by same physician) should be used to indicate that a procedure or service was repeated subsequent to the original procedure. According to the AMA CPT Manual, modifier 76 was revised to designate the intent of the procedure to be used to report repeat procedures, as well as repeat services provided by the same physician.

As indicated in the definition of modifier 78, modifier 76 is not restricted to procedures performed on the same day. Modifier 76 is applicable to both surgical and diagnostic procedures and services that are repeated. It should not be used for planned or anticipated subsequent or staged procedures or related unplanned procedures (such as for complications).

If, for example, a physician reduces a distal radius fracture in the office on May 15 and the reduction is lost so that the fracture must be reduced a second time on May 22, the physician would report CPT code 25605 (Closed treatment of distal radial fracture [eg, Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation) for the May 15 visit and 25605-76 to indicate a repeat reduction for the May 22 visit.

Source: CPT Changes: Insiders Edition 2000-2008.
I think that two visits on the same day for different problems does not meedt the definition.
 
The post from Soundar says the visits were for unrelated problems. According to the post from Rebecca (I copied her reference from CMS below), it looks like both should be billable. I would try putting the times of the visits in the comment field or send the office notes.


Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

Michele R. Hayes, CPC, CEMC, CGIC
 
But again...for the purpose of Medicare, you need to combine the services...."Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level"....

For other carriers, that don't follow CMS guidelines, it's possible to bill for both. It will depend on that's carriers guidelines. Like most, once Medicare sets a "standard", others follow suit.
 
I agree Rebecca, our clinic combines the visits and codes appropriately. And we're finding that more and more carriers are following Medicare guidelines.
 
First, the 27 modifier is for facility billing only.
Second, if your NPs are in the same specialty, then you will not be successful with trying to bill 2 visits on the same day. If you provide more information I might be able to give more help. Such as are both NOPs in same tax ID, and what was the dx for each encounter, and the need for 2 encounters on the same day.

Thanks for you Kind reply...

Two NP's are belong to same group & having Same Tax ID. Herewith i have given some patient visits... Please help me by checking these examples

Patient 1:
1st visit - 707.03 & CPT 99255
2nd visit - 682.6,465.9 & CPT 99309

Patient 2:
1st visit - 707.03 & CPT 99308
2nd visit - 783.21,454.0,285.9 & CPT 99310

Patient 3:
1st visit - 892.0 & CPT 99307
2nd visit - 482.9,428.0,288.50 & CPT 99316

In all above said visits, I billed it with 27 & got denied from Medicare. Now what i have to do to bill this visit, if there is no other modifier means can i move second visit to patient directly from MCR.

Once again Thanks for your Kind timely help

Thanks,
Soundar
 
I'm with Debra on this....

Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

30.6.5

Hi Rebecca,

Thanks for this wonderful link..

I have sent the examples in previous thread, please check with that also & help me

Thanks,
Soundar
 
Thanks for you Kind reply...

Two NP's are belong to same group & having Same Tax ID. Herewith i have given some patient visits... Please help me by checking these examples

Patient 1:
1st visit - 707.03 & CPT 99255
2nd visit - 682.6,465.9 & CPT 99309

Patient 2:
1st visit - 707.03 & CPT 99308
2nd visit - 783.21,454.0,285.9 & CPT 99310

Patient 3:
1st visit - 892.0 & CPT 99307
2nd visit - 482.9,428.0,288.50 & CPT 99316

In all above said visits, I billed it with 27 & got denied from Medicare. Now what i have to do to bill this visit, if there is no other modifier means can i move second visit to patient directly from MCR.

Once again Thanks for your Kind timely help

Thanks,
Soundar

It is not making sense to me why there is a need for these as two separate encounters on the same day by NPs in the same practice and same specialty. In example 1 why a consult and a nursing home visit on the same day, when one of the providers could have assessed all three problems. And the same wth each of the other scenarios. Is there anything in the documentation that supports why it was necessary to be examined on two different visits on the same day?
As previously stated you cannot use a 27 modifier for physician billing. And as Rebecca pointed out you should combine the visits for one E&M code.
Also on the last visit why one visit and then a discharge on the same day. I am sorry that I am not being more helpful but this just does not make sense to me. Any thing else you can give me?
 
It is not making sense to me why there is a need for these as two separate encounters on the same day by NPs in the same practice and same specialty. In example 1 why a consult and a nursing home visit on the same day, when one of the providers could have assessed all three problems. And the same wth each of the other scenarios. Is there anything in the documentation that supports why it was necessary to be examined on two different visits on the same day?
As previously stated you cannot use a 27 modifier for physician billing. And as Rebecca pointed out you should combine the visits for one E&M code.
Also on the last visit why one visit and then a discharge on the same day. I am sorry that I am not being more helpful but this just does not make sense to me. Any thing else you can give me?

Thanks for your kind reply, i asked the same question to my NP's & im waiting for their reply.. If i got correct reply means, then i will message you to your id about those details.

Once again thanks, Have a nice day

Regards,
Soundar
 
What if it is two visits in a nursing home. Both doctors are from the same clinic but one is a Mental health and the other a Family doctor. Would we use the prolonged services codes or a modifer. Both are billing 99308.

THanks,
Emily:)
 
They are different specialties so each codes their own services. Would also expect the DX to be appropriate for their specialty
 
E/M done same day with procedure done later that day? what modifier

Hi,
My physician did a consult in the ER at 2:30 in the a.m. Pt was later admitted that same date and my physician came in to place a chest tube. In this case, would I add modifier 59 to the chest tube placement. I thought about the 25 modifier but they were not at the same session.
Thoughts please
right now I'm thinking 99284
32551-59?

Thank you,
Marci
 
same day, different procedure, different surgeon

What about for facilities? We have an ENT seeing a peds pt in the morning to do one procedure. The patient is then seen by the Ortho for a separate. They are scheuled on the same day so the peds patient does not have to go under twice. Can we bill separately for both procedures or would they count as multiple? Remember- different specialties and different surgeon. No assisting or other communication between the two.
Thanks!
 
I agree 76 modifier is not for EM, I am having the same problem, I have 2 different specialty's but same tax id. One is on oncologist and the other is radiologist . What modifier if any would separate these dr's.
 
modifier two visits same day

Debra,

What if it is a TMS therapy session and a psychiatrist med management visit in the same day? Same tax id same specialty but two totally different procedures.
90868 and 99214 are they ok to bill separately? Or do I use modifer 25?

thanks
 
I work for a group that has ER Physicians and Hospitalists. Trying to find the guidelines/modifier to use when a patient goes to ER, is seen by ER Physician, then is admitted by a Hospitalist (different specialty). For some reason I am having trouble finding the information.

Thank you,

Dawna Cornett, CPC, CPMA
 
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