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same dr same pt same dx same day?? in ED

kviolet

Networker
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84
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Hi ALL !
What is the rule in ED pt coming back and is seen by same dr and it is same dx or diffrent dr on same dx?
thanks
 

sjb280

New
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Hi, I work for a billing co that does Er billing and my understanding of your question is...if the pt is seen twice in one day by the same doctor with the same dx...then you can bill the first visit out to an 85 or however far it codes out to. The second visit you will be as an established pt, ( or recheck) and it should only code out to an 81 or 82 ( improving or worsening). If the patient presents a new problem in the second visit, like at the first visit they had a cough, but at the second visit they have a cough and knee pain, you can code the second visit as a new pt, not established, and code it out that way. But the doctor has to state the new problem, if there is one. Does that make sense?
If the pt is seen first by one doctor and then by a different doctor both with the same dx....I'm not sure I can answer that because the doctors I deal with are all in the same group. So if the doctors you are asking about are in the same group....the same answer as above applies. If the 2nd doctor is in a different group than the 1st doctor hopefully somebody can answer that for you. Hope that helps :)
 

RebeccaWoodward*

True Blue
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3,126
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North Carolina
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Q12. If a patient sees his/her provider early in the day and later that evening the patient is seen in the ER for an unrelated condition by same provider, can a physician bill for two E/M visits at two different places of service?
A12. No. If the same physician sees the patient in the clinic and again later that same day in the ER, all services should be considered and the provider should bill the code that most closely represents the services given. It may be appropriate to bill a slightly higher code to accommodate both visits.

Addendum:
The above answer reflects a situation where the patient is subsequently admitted to the hospital after being seen in the ER.

If the patient is not hospitalized, Contractors may not pay two E&M 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. Example of this would be an office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident. Source: Centers for Medicare and Medicaid Services (CMS) Internet Only Manuals (IOM) Publication 100-04, Chapter 12, Section 30.6.7.B.

If the second situation should arise, the claim may deny and providers may have to go through Redeterminations to seek payment for the second visit. Updated March 9, 2007

https://www.noridianmedicare.com/macj3b/train/act/qa/act_qa_111606.html
 

jccoder

Networker
Messages
43
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0
Hi, I work for a billing co that does Er billing and my understanding of your question is...if the pt is seen twice in one day by the same doctor with the same dx...then you can bill the first visit out to an 85 or however far it codes out to. The second visit you will be as an established pt, ( or recheck) and it should only code out to an 81 or 82 ( improving or worsening). If the patient presents a new problem in the second visit, like at the first visit they had a cough, but at the second visit they have a cough and knee pain, you can code the second visit as a new pt, not established, and code it out that way. But the doctor has to state the new problem, if there is one. Does that make sense?
If the pt is seen first by one doctor and then by a different doctor both with the same dx....I'm not sure I can answer that because the doctors I deal with are all in the same group. So if the doctors you are asking about are in the same group....the same answer as above applies. If the 2nd doctor is in a different group than the 1st doctor hopefully somebody can answer that for you. Hope that helps :)
Per CPT, no distinction is made between new and established patients in the ED. We bill for both visits and apply E/M codes per documentation and add modifier 27 to the 2nd visit.
 

sjb280

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-jccoder- thank you for clearifying that. It's the coding software the company I work for that uses the established pt in the er vs the modifyer 27....at least at the point where I enter the information....it does come up on the claim form. I am still a pretty new coder and forget that not everybody uses the same systems that I do. :( But I won't forget that again if I should try and provide an answer. I probably won't for a while because I have alot more to learn....this forum provides alot great information!
 
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