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Two Different Specialties same Doctor

stlbill511

Networker
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53
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0
CAn the same doctor who is credentialled in Psychiatry and Neurology, bill the same patient for a psych visit and then sees the same doctor for neurology on the same day? It is a different specialty by the same doctor on the same day.
 

CodingKing

True Blue
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3,955
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1
Its 1 E&M per provider per day. Different specialties come into play when its two providers on the same day or when determining new vs established for existing patient in a group practice. It might be possible to bill the prolonged services add-on codes or maybe get to a higher level when the components of both visits are combined.
 
Last edited:

stlbill511

Networker
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53
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Do you know where I could find that in writing? I have looked through the E/M Guidelines and don't see anything that says one e/m per day per physician. Thanks for all the help.

Caroline
 

CodingKing

True Blue
Messages
3,955
Best answers
1
Do you know where I could find that in writing? I have looked through the E/M Guidelines and don't see anything that says one e/m per day per physician. Thanks for all the help.

Caroline
Check with the payer. Not all the information you need is in the DG's or the CPT book. Also payers can be more strict than what the AMA writes in the CPT book.

Examples

Moda Health:

https://www.modahealth.com/pdfs/reimburse/RPM028.pdf

Multiple E/M Services

Only one E&M service code per patient, per physician, per day is eligible for reimbursement, with
the following exceptions:

 Two separate visits occurred at different times of day and for unrelated problems that could
not be anticipated or addressed during the same encounter.


o For example, a scheduled office visit occurs in the morning for upper respiratory
infection and 4 hours later an unscheduled visit for a fall with injured knee.

o Modifier 25 would be appended to the second visit. Additional information
regarding the two separate times should be supplied in box 19 of the claim form, or
the equivalent field in the electronic claims submission process.

o Note: If the patient mentions the second problem at the first visit, and the provider
asks the patient to return later in the day for the assessment of the second problem,
then all evaluation and management services provided that day would be included
in the selection of a single E/M service code.
Empire Blue:

https://www.empireblue.com/provider/noapplication/f4/s2/t0/pw_ad067872.pdf

Multiple Evaluation and Management (E&M)
Visits on the Same Date of Service

Empire will allow only the E&M service with the highest
allowed value when more than one E&M service is
billed for a member for a given date of service for the
same or similar condition. This policy is adopted from
CMS and also defines the provider according to their tax
identification number (TIN) and specialty.

If more than one E&M service per day is reported by the
same provider, the provider should bill a level of service
representative of the combined visits.
Harvard Pilgrim:

Multiple E&M Services - When multiple providers using the same federal tax identification number perform evaluation
and management (E&M) services on the same patient, on the same day, for the same or related condition, Harvard Pilgrim
will reimburse only the E&M service with the highest allowable amount. Harvard Pilgrim’s policy is to reimburse
for only one E&M service per day under the above conditions, regardless of whether services are performed by providers
with different specialties.
United Healthcare

https://www.unitedhealthcareonline....entPolicies/SDSS_Same Day Same Svc_v2011A.htm

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. However, there are instances when modifier 25 would not be appropriate to report, including but not limited to, reporting two E/M services where one is a "per day" code or reporting separate services when a more comprehensive code exists that describes the services.
 
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