Wiki Office visit and hospital admit

[carolanntomko]

Patient came to office, history, exam, MDM all completed; other things were done; like CBC and a chemo flush; 99215 with a 25 modifier was used; on the same day, the patient was admitted by the same doctor; history, exam etc. completed - for a initial hospital visit - 99223; can both E&M codes be reported?

 

[Jacqueline.Alexander]

No, unfortunately he will not be reimbursed for both encounters. In matter of fact, even if two separate physicians from the practice conducted the visits it wouldn't be reimbursed. An E&M and an admit on the same day is only reimbursable if the claims are filed under different provider numbers.

 

[OCD_coder]

If the two encounters were for related problems, then No the provider or group cannot bill for 2 E&M's on a single DOS. But if the documentation shows two unrelated problems were evaluated, then the answer is Yes! And furthermore, a modifier 25 will be need on one of the E&M, it doesn't matter which one. Also, remember all documentation Office/H&P Admit notes can be combined to support a E&M level, this would be beneficial if the two encounters were for related problems and performed by two different providers within the same group.

Source: Chapter 12, CMS Claims Processing Manual
30.6.7 - Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99201 - 99215)

B Office/Outpatient E/M Visits Provided on Same Day for Unrelated Problems
As for all other E/M services except where specifically noted, carriers may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office or outpatient setting which could not be provided during the same encounter (e.g., office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident).