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

February 9th, 2009 - Codapedia Editor
Categories:   Coding   Evaluation & Management (E/M)  
0 Votes - Sign in to vote or comment.

 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.



Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.

Latest articles:  (any category)

HIPAA Penalty Changes
January 11th, 2021 - Wyn Staheli, Director of Research
On January 5, 2021, H.R. 7898 was signed into law by President Trump. This new law modifies the HITECH Act such that when an organization experiences a breach, fines and/or penalties may be reduced if (for at least a year) they have instituted “recognized security practices” as defined within the law.
CDT and CPT - The Same but Different!
December 8th, 2020 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Reporting a CPT code for an evaluation of a patient is based on time and if the patient is a new or established patient. Evaluation and Management codes are different than other codes, it is important to understand how they are used, prior to 2021 they were based on a ...
How to Search Find-A-Code for Medicare Policies and Guidelines — LCDs, NCDs and Articles —
November 18th, 2020 - Raquel Shumway
Help for Searching Find-A-Code when searching for Medicare Policies and Guidelines — LCDs, NCDs and/or Articles.
Cross-A-Code Instructions in Find-A-Code
November 18th, 2020 - Raquel Shumway
Cross-A-Codeis a toll found in Find-A-Code which helps you to locate codes in other code sets that help you when submitting a claim.
COVID Vaccine Codes Announced
November 11th, 2020 - Wyn Staheli, Director of Research
On November 10, 2020, the American Medical Association (AMA) announced the addition of two new codes which will be used for the new COVID-19 vaccines along with 4 new administration codes to be used when reporting the administration of these vaccines.
Are You Aware of the 2021 Star Rating System Updates?
November 5th, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Each year the Centers for Medicare & Medicaid Services (CMS) publishes the Star Ratings System Updates for Medicare Advantage (Part C) and Medicare Prescription (Part D). This rating system was developed to help beneficiaries identify and select the health plans that best meet their needs, specifically addressing main issues:  Quality of ...
Special Needs Plans Help Beneficiaries and Risk Adjustment Reporting
October 22nd, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
It is no secret that Medicare and Medicaid are steadily moving towards their goal of value-based health care. Medicare Part C (Medicare Advantage) identifies and rewards payers, and subsequently their providers, for increasing the efficiency and quality of care they provide to Medicare...

Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2021 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association