Are two E/M services payable on the same day?

February 9th, 2009 - Codapedia Editor
Categories:   Coding   Evaluation & Management (E/M)  

 Discharge from an inpatient service and admission to a nursing home, same day.

A physician who discharges a patient from the hospital and admits the patient to a nursing facility may be paid for both services.  However, the physician must physically go to the nursing facility, see the patient and perform all of the key components for a nursing home admission.  It is insufficient to bill the patient if this is the service provided:  see the patient in the hospital, call in the orders/write a brief admitting note while still in the hospital and send the paperwork with the patient. 

This is what the Medicare Claims Processing Manual says, in Chapter 12
D. Hospital Discharge Management (CPT® Codes 99238 and 99239) and Nursing
Facility Admission Code When Patient Is Discharged From Hospital and Admitted
to Nursing Facility on Same Day

Contractors pay the hospital discharge code (codes 99238 or 99239) in addition to a
nursing facility admission code when they are billed by the same physician with the same
date of service.

Two office visits on the same day

Medicare will only pay for two office visits on the same day, if they are unrelated.  A second office visit billed on the same day to the same patient for the same condition is not payable.  If a patient is seen in the morning with an acute or chronic problem, sent home from the office, and returns later either at the physician's request or because their symptoms are worse, report only one visit.  The level of service selected may be based on the documentation for both services.  If the second visit is all provider face-to-face time with the patient, consider using prolonged services codes.  Review the rules for that in the Codapedia article on prolonged services.

From the Medicare Claims Processing Manual, Chapter 12

B  Office/Outpatient E/M Visits Provided on Same Day for Unrelated Problems
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).


Two hospital visits on the same day

Physicians often see their hospitalized patients more than once in a single day.  The patient's condition may require frequent visits, or the physician or covering partner may be called back to the hospital because the patient's condition worsens.  It is a source of huge frustration to physicians that they do not get paid extra for multiple visits.

All of the hospital services (initial or admissions, subsequent or rounding and discharge day services) are defined by both CPT® and CMS as per diem services, as the care of the patient for the entire calendar date.  That means, there is no extra reimbursement or RVUs for the second visit, whether performed by that physician or a covering partner.

Medicare, and other payers, pay for physicians in a group of the same specialty as if they were the same physician.  They don't differentiate between the two.

If the patient is critically ill, there is additional payment for additional services provided.  Be careful: just because a physician is called back to see an ill patient does not mean critical care can be reported.  Review the requirements for critical care.

Sometimes, prolonged services may be reported.  Again, use caution to be sure that the services being reported were all face-to-face services.  Although CPT® changed their definition of prolonged services in a hospital to be unit time, CMS did not.  CMS still requires that prolonged services provided in the office or hospital setting be face-to-face time with the patient.



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