Wiki Repeat E/M Service Modifier

ndovgalacarr

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I've been seeing claims denied by insurance because it is the second claim for the same date of service that has the same CPT code (e.g. 99282) but the two E/M services were billed by different providers in the same hospital. The payer said that they will pay for both but they need the appropriate modifier, and I can't figure out what modifier to use. Modifier 77 seems to be best, but I thought that can't be used for E/M services. Does anyone what to do with this?
 
For some of the claims, the providers are the same specialty and work for the same employer, but for others they're not the same. It's a mix of the two
 
Same specialty, same employer, you don't get to bill two visits in one day. You combine the work into one.

Different specialty, same employer, you can bill.

Different employers, you can bill.

Appeal with notes if you need to do so.
 
Most payers have a policy with guidance on when they will allow multiple E&M visits on the same day and it is usually only in exceptional circumstance such as when the patient returns the same day for a completely unrelated problem that was not addressed at the first visit. In these cases, you may apply a 25 modifier to the second service but in my experience, it will likely still deny anyway, but may be overturned on appeal if the documentation shows that the payer's criteria for separate payment has been met. But as a general rule, if the two providers are of the same specialty and group and are seeing a patient for a related issue, these should be combined and billed as one service.

The Medicare guidance can be found in section 30.6.4 of the Claims Processing Manual, Chapter 12:

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.
Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group.


As a example for a commercial payer, here is the UnitedHealthcare commercial policy for multiple E&M services on the same day:

As stated on page 3 of the policy:
UnitedHealthcare will allow modifier 25 to indicate a significant and separately identifiable E/M service when a second physician in the same group and specialty provides a separate E/M service on the same day for an unrelated problem.
 
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Thank you for the addition, Thomas. I wasn't thinking about an office situation, as the original CPT was an ER visit. One ER visit in one day is bad enough, but more than one? YIKES! :oops:

Sharon
 
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