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Problem: 2 Specialties, 2 E/Ms, Same Day

  1. #1
    Cool Problem: 2 Specialties, 2 E/Ms, Same Day
    Exam Training Packages
    I bill for a cardiologist, as well as an electrophysiology sub specialist. We are not only getting denials from insurance for the subspecialties, but against visits by other physicians (internal med or even a different specialty--we have over 65 MDs in 22 specialties) of our practice on the same day. There is one insurance in particular that still says there is a concurrent care modifier that needs to be put on these claims, but will not tell us what one they want.

    For example: Patient is admitted to inpatient for chest pain and abnormal EKG. The day after admission, the patient is seen for a subsequent hosp visit by our cardiologist (dx 786.50) and our nephrologist (dx 276.8). The visit for the cardiologist was denied as bundled. Even after submitting an appeal with the notes from both physicians showing the necessity, they continue to uphold their denial, stating we need to append the concurrent care modifier. In one letter, they even go on to say that "this situation may be reported by adding modifier 77 to the repeated procedure/service". By all documentation that we find, a 77 cannot be put on an e/m service.

    Is this type of situation something that would justify a 25 modifier? We have always thought of the 25 to be a separate procedure by the same physician.

    If anyone else has ran into this and found a solution, or a reference to check out, your help would be greatly appreciated.

  2. #2
    Location
    Seacoast- Dover New Hampshire
    Posts
    609
    Default
    We have similar problems here. We make sure to use different diagnosis codes for the different specialists. The 77 modifier does not look right to me, but if the ins co wants it, I would put it on with the documentation stating you are suppose to use it. Good luck
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  3. Default Precision Practice Management Director of Operations
    See CPT Appendix A mod 27 for OP Hospital E/M encounters this may help with some of the rejections. Since this case is inpatient service I would use a modifier 25 on the service because most likely there is something linking the two providers such as tax ID billing address etc. The diagnosis codes should support the separate service.

    The description reads" same physician on the same day of the procedure or other service" other service being the reason to use mod 25 in this case.

    Medical Necessity must be documented. See Medicare Benefits Policy Manual, Chapter 15, Section 30.E. Available at: http://www.cms.hhs.gov/manuals/102_policy/bp102c15.pdf. Accessed Sept. 30

    Google concurrent care there are some good articles on getting paid. Hope this helps.

    I ran across this info:

    From a Medicare perspective, concurrent care exists "where more than one physician renders services more extensive than consultative services during a period of time."1

    Practically, this translates into two or more physicians billing the same service (usually subsequent hospital care) for the same patient on the same date, sometimes with the same diagnosis. In the example above, concurrent care would occur if both the family physician and the cardiologist submitted a claim to Medicare for subsequent hospital care provided to the same patient on the same date of service, especially if they both listed the heart condition as a diagnosis on their claim forms.

    Note that under Medicare's definition, a consultation with another specialist wouldn't be considered concurrent care. Thus, if the cardiologist provided an inpatient consultation at the request of the family physician and billed Medicare for a consultation rather than subsequent hospital care, concurrent care would not be an issue
    Last edited by sappjacque; 05-05-2009 at 02:50 PM.

  4. #4
    Default
    sappjacque can you please give me the description of the 27 modifier? When I look in our 2008/2009 AMA Cpt book, there is no 27 mod.

    As far as the 25 goes, it states "separate e/m by [U]same[U] physician on the same day as procedure or other service". These are truly 2 separate physicians/specialties. Although we do share the same tax ID and billing address, each physician has their own individual NPI. It is very frustrating that the AMA does not recognize this problem and have a modifier to clear it up.

    Our Medicare carrier pays our concurrent care claims with no problem. It is most of our commercial carriers that kick these out. And for the most part, they will reprocess with a simple phone call. There is just one company in particular that seems to drag their feet and refuse to recognize the multiple specialties on the same day. (even after submission of the medical records)

    Thank you everyone for all of your help. These kinds of situations are so confusing. It is nice to know that we aren't alone!!

  5. #5
    Location
    North Carolina
    Posts
    3,126
    Default
    We are also multi-specialty. There are occasions when we receive a denial for our second claim. Typically, I send them Medicare's policy on "multiple visits, same day, different specialites" and the denial is overturned. Many of carriers follow Medicare's guidelines; therefore, they really don't have anything else they can dispute. This particular carrier you're having problems with...have you checked to make sure the physicians are credentialed appropriately with their specialty?

    As for Modifier 27...it's listed on page 480 in my 2009 CPT book.

  6. #6
    Default
    I also work for a cardiologist practice which includes several electrophysiologists... We have ran into similiar situations. We have found that each claim has to have a different diagnosis and often times we have to appeal the claims with a 25 modifier and documentation(sometimes we even have to send in a copy of the EP doctors specialty license). Hope this helps.

    MM

  7. Default
    Quote Originally Posted by sappjacque View Post
    See CPT Appendix A mod 27 for OP Hospital E/M encounters this may help with some of the rejections. Since this case is inpatient service I would use a modifier 25 on the service because most likely there is something linking the two providers such as tax ID billing address etc. The diagnosis codes should support the separate service.

    The description reads" same physician on the same day of the procedure or other service" other service being the reason to use mod 25 in this case.

    Medical Necessity must be documented. See Medicare Benefits Policy Manual, Chapter 15, Section 30.E. Available at: http://www.cms.hhs.gov/manuals/102_policy/bp102c15.pdf. Accessed Sept. 30

    Google concurrent care there are some good articles on getting paid. Hope this helps.

    I ran across this info:

    From a Medicare perspective, concurrent care exists "where more than one physician renders services more extensive than consultative services during a period of time."1

    Practically, this translates into two or more physicians billing the same service (usually subsequent hospital care) for the same patient on the same date, sometimes with the same diagnosis. In the example above, concurrent care would occur if both the family physician and the cardiologist submitted a claim to Medicare for subsequent hospital care provided to the same patient on the same date of service, especially if they both listed the heart condition as a diagnosis on their claim forms.

    Note that under Medicare's definition, a consultation with another specialist wouldn't be considered concurrent care. Thus, if the cardiologist provided an inpatient consultation at the request of the family physician and billed Medicare for a consultation rather than subsequent hospital care, concurrent care would not be an issue
    I also found this info on CMS site supporting the use of the mod 25:

    Special situations
    Occasionally two physicians in the same group with the same specialty (but different subspecialties) see the patient on the same day. Medicare does not recognize subspecialties on front-end claims processing. The physician may use Modifier 25 if the documentation meets the definition above. Please submit the documentation when requesting a redetermination.
    2

  8. #8
    Default Modifier 27
    Modifier 27 is not a Physician modifier, it is approved for ambulatory surgery center (ASC) and Hospital OP use only.

  9. Default Help with Global periods..
    I have one Dr completing fracture package on one day and another Dr from a subspecialty completing another eval 1 1/2moths later on same issue..
    are these separately payable per the Subspecialty guidelines and what is required in order to do this.. i remember vaguely reading that they need another NPI under the subspecialty or something to that effect.
    Please help asap
    -D

  10. #10
    Location
    albuquerque
    Posts
    93
    Default mod 25 and strep or urinalysis
    has anybody out there heard of a policy indicating when a strep was done in the office or a urinalyis test along with an e/m visit we must append a mod 25 to the e/m if so, can you please give me the reference?
    thanks a lot
    Angelica Stephens RHIT, CPMA, COSC, CCS-P, CPC, COC.
    Albuquerque, NM

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