I had a patient who presented as a new patient to be seen for two body parts after a fall and hurt their knee and shoulder. They are VA (Veteran Affairs, Tricare- CCN). There is two separate auths for both body parts.
I had been looking into potential resolutions to this questions as much as I can and haven't been able to really answer. What I'm finding in my search is very conflicting as some say do this and some do that.
In usual practice, we have them scheduled on separate days when being seen for a different body part to avoid this conflict, however in this case, this patient was seen for both (shoulder and knee) by one provider in same session. same day. This would not be a conflict if there was only one auth with both body parts and if it was any other payer (commercial/private, cms), I would code into one encounter claim. This case is little different having there is two diff auths.
A lot of the research I've been digging in both google, the community forum and other resourceful websites, doesn't really point me in a direction I feel confident enough to attempt.
Most of the questions and resolutions are in response to patients being seen for either an annual and then a problem visit, or seeing two different physicians in the same practice same day, which is common with our practice as we are ortho- these I am more confident on how to resolve.
Would this be appropriate to code as two new patient visits with second E/M appended mod 25? From my research, a new patient can not be new twice, but then insurance may kick back if they are seeing that patient is a new patient and est same day with same provider... VA usually follows CMS guidelines but also have their own set of rules with certain billing processes.
Would it be appropriate to code as one new e/m combining the total time and then later appeal that they were separately identifiable and there were auths for them?
Would we have to decide on coding the higher e/m visit and eat up what would be the second e/m because it was a mistake on our end to see patient same session?
What have you tried that has worked (reimbursed by VA) for a similar or scenario like this?
Any guidance and educational expertise share is appreciated!
I had been looking into potential resolutions to this questions as much as I can and haven't been able to really answer. What I'm finding in my search is very conflicting as some say do this and some do that.
In usual practice, we have them scheduled on separate days when being seen for a different body part to avoid this conflict, however in this case, this patient was seen for both (shoulder and knee) by one provider in same session. same day. This would not be a conflict if there was only one auth with both body parts and if it was any other payer (commercial/private, cms), I would code into one encounter claim. This case is little different having there is two diff auths.
A lot of the research I've been digging in both google, the community forum and other resourceful websites, doesn't really point me in a direction I feel confident enough to attempt.
Most of the questions and resolutions are in response to patients being seen for either an annual and then a problem visit, or seeing two different physicians in the same practice same day, which is common with our practice as we are ortho- these I am more confident on how to resolve.
Would this be appropriate to code as two new patient visits with second E/M appended mod 25? From my research, a new patient can not be new twice, but then insurance may kick back if they are seeing that patient is a new patient and est same day with same provider... VA usually follows CMS guidelines but also have their own set of rules with certain billing processes.
Would it be appropriate to code as one new e/m combining the total time and then later appeal that they were separately identifiable and there were auths for them?
Would we have to decide on coding the higher e/m visit and eat up what would be the second e/m because it was a mistake on our end to see patient same session?
What have you tried that has worked (reimbursed by VA) for a similar or scenario like this?
Any guidance and educational expertise share is appreciated!
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