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Thread: 2 E.D. visits same day 99283/99284

  1. #1

    Default 2 E.D. visits same day 99283/99284

    AAPC: Back to School
    Is the E.R. doctor allowed to bill 2 E&M on the same day? patient came in the morning, dx:colitis, came back in the evening same day with vomitting/nausea...
    Marilyn CPC, CPC-H, CEMC

  2. #2



    Yes you can bill two visits.

  3. #3
    Join Date
    Apr 2007

    Default only in certain circumstances...

    Hi there,

    My experience is actually quite different - I believe that there are few circumstances that allow you to bill 2 visits by the same specialty on the same DOS. i.e. I would not bill a 99283 and a 99284 on the same DOS for the same PT. My belief is that one E/M will be denied outside of certain situations.
    We get denials from visits where the PT has been seen in another ED on the same DOS, and I do not believe that the denials are dx related.
    An E/M and then Critical Care services on the same DOS are billable, in which case one would add a -25 modifier to the initial service.

    If a patient has 2 visits on the same DOS in our ED, we accumulate the time and effort from both visits and bill one E/M. In the event that someone has identifiable visits with different carries (i.e. bronchitis at 8am, and then back pain from an MVA at 10am - and therefore health and then MVA insurance), we bill those separately. With procedures, a -76 or a -77 modifier may apply, but those are worth exploring on a case-by-case basis. In my experience, even if we had a patient come in once with sinusitis and then later with a broken wrist from a fall at home, we would not bill two separate E/Ms.

    From the CMS website (and I think it can be applied for ED as well - I could not unfortunately find explicit language about "2 visits in the ED on the same DOS", though that is the same as "two visits in the same specialty" so...):
    "The Medicare Claims Processing Manual (Chapter 12, Section 30.6.7), Paragraph B, clarifies “physician in a group practice” for office/outpatient E/M visits provided on the same day of unrelated problems, are as follows:
    • As for all other E/M services except where specifically noted, carriers may not pay two E/M office 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 (e.g., office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident)."
    [from] http://www.cms.hhs.gov/mlnmattersart...ads/MM4032.pdf

    Also, the discussion in the forum about critical care services and other E/M services on the same DOS may be helpful.
    I hope this helps...sorry if a bit long-winded.

    It would be great to see a reference either way (that it's explicitly ok in the ED, or not) - anyone have one?

    would love to know.
    good luck!
    Last edited by spstarke; 02-12-2010 at 10:03 AM. Reason: to clarify.

  4. #4


    Thank you very much for all your info. it was great...
    Marilyn CPC, CPC-H, CEMC

  5. #5
    Join Date
    Apr 2007


    I am going to ask my supervisor how this process works for us because I have noticed that we have many return visits in the same day by the same PT. We do not use a modifier on the E/M though I will not be able to ask until Monday now. This is something I have wondered about myself when I see a return visit. One day recently I noticed the Dr had written on the record that this was the second visit this day so I checked the system for another visit and discovered this patient had been there 57 times in a two month period (psych case). To say the least this got me wondering how they were all paid. When I recieve an answer I will post it, if I get an answer.

  6. #6
    Join Date
    Apr 2007


    Here is the way we proces a return visit within same date for the same DX. First the Dr needs to document the return visit or we would not recognize it as so, we do not check the system for each visit each pt.
    If it is for a commercial ins we code as usual and apply a modifier 25 ; for Medicare we void/no charge the entire visit. And thank you mmunoz21 for posting this question.

  7. #7
    Join Date
    Apr 2007


    on the facility side we afix a modifier 27 on the second visit:

  8. #8

    Default 2 er visits same day

    We also combine the 2 visits. The CMS rule regarding paying 2 visits/ same specialty/same day does usually hold true unless the visits are totally unrelated. We look at both visit notes and combine the time and documentation and choose our level of E/M by that. ER physicians are usually in the same group so all the money goes to the same place anyway. Use both DX codes and if you have to appeal it, send both notes.

  9. #9


    Can anyone help?
    How to code, if two ER visits are billed for same patient by same physician for same diagnosis on same DOS in different invoices?


  10. #10

    Default For same reason

    Many ED coding entities will combine the two visits based on total documentation and bill only once. The reason is usually that if a patient returns for the same reason or symptoms were not resolved, the hopsital will not want to penalize the patient for what may have been an oversite by ED providers,
    also I believe many payors will not pay in the scenario you described based on medical necessity.
    If the pateint came in for an ankle sprain and returned for chest pain, that is a strong argument for billing twice. But in your scenario, better to combine. If you do bill twice use 25 modifier for physician and 27 for facility.

    Jim S.

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