AAPC - Back to school
Results 1 to 7 of 7

Thread: 2 providers/2 visits - same patient/same day...billable?

  1. #1
    Join Date
    Apr 2007

    Default 2 providers/2 visits - same patient/same day...billable?

    AAPC: Back to School
    I have a PA and a physician from the same group seeing the same patient on the same day. The PA does the E/M portion and the physician does a facet joint injection. Can they be billed separately or should I bill under the physician both the E/M (with 25 mod) and the injection? Also, same goes with 2 PAs seeing the same patient on the same day for different injections. Is that billable? Would someone please direct me to a good resource for these instances? Thanks.

  2. #2
    Join Date
    Apr 2007


    The claims processing manual and the NCCI policy manual for medicare services were the two resources that I think you cou obtain some helpful information. The confusing thing about your question is you did not state if was an establlished or new patient. To me, if was an established patients and they were coming in for a facet block there would be no separate E/M charge. If they were a new patient I would assume the physician would have to be the one seeing the patient not the PA.



    If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an
    E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.
    The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers (A/B MACs processing practitioner service claims) have separate edits. Neither the NCCI nor Carriers (A/B MACs processing practitioner service claims) have all possible edits based on these principles.
    Example: If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological examination, an E&M service may be separately reportable.
    Procedures with

  3. #3
    Join Date
    Apr 2007


    Thanks for the info. To clarify the situation, an established patient is scheduled for an injection with the physician on the same day the patient is scheduled to see the PA for an E/M visit (but for the same dx). If the injection was planned, there is no need for the E/M, but the practice is wanting to bill that way. I need to show them that this is not correct and haven't been able to find any resources to provide them. They are also scheduling the same patient on the same day with either a physician and a PA, 2 PAs, or 2 physicians to do different injections. That doesn't seem right to me either, but again, I need to provide evidence that it is not correct. Any suggestions?

  4. #4

    Smile 2 providers/2 visits

    I would be careful about making rules about E&M on the day of procedure, because if the documentation supports the E&M service it is billable with a 25.

    Here is our carriers E&M manual- Look at pages 12-17 for clarification


    Hope that helps!


  5. #5
    Join Date
    Apr 2007



    Here is another resource that you can share with them regarding the use of the 25 modifier.

  6. #6
    Join Date
    Apr 2007


    After reviewing the definition of the 25 modiifer. I think what you need to point out to them is that appropriate use of the 25 modifier is following the descriptor of the modifier. It says


    so it would be incorrect reporting the 25 modifier on the PA visit.

    Below is from Medassets.

    25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

  7. #7
    Join Date
    Apr 2007


    Thank you all for your assistance!

Similar Threads

  1. Two visits ED, same day MD patient
    By rogers in forum Emergency Department
    Replies: 2
    Last Post: 09-16-2012, 11:08 PM
  2. Inpt : Providers completing visits for former providers
    By Chrisd in forum Billing/Reimbursement
    Replies: 1
    Last Post: 12-02-2011, 09:29 AM
  3. CABG day 1 and return to OR day 2 is it billable?
    By nissajlo2 in forum Cardiovascular Thoracic
    Replies: 3
    Last Post: 04-05-2011, 07:08 PM
  4. 2 Visits, 2 different Providers
    By Valerie813 in forum E/M
    Replies: 5
    Last Post: 04-01-2011, 06:44 AM
  5. Replies: 1
    Last Post: 11-17-2010, 03:36 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.