Forum - Questions & Answers

Jun 4th, 2021 - Dawna 1 

ER/Hospitalist Professional Visits

I work for a company that employs ER Physicans and Hospitalists so if patient is admitted there is an ER visit by ED Physician followed by Admission by Hospitalist. Since different specialty I am sure I can bill for both but am trying to find the guidelines and for some reason having trouble with it. I know there is a modifier I should be using for the second visit. Thank you, Dawna

Jun 8th, 2021 - ChrisW   256  1 

re: ER/Hospitalist Professional Visits

Both physicians should bill for their services on the CMS-1500, the ER Doc for Emergency Department Services using a 25 modifier (because of testing/diagnostic). If there was a decision for surgery remember to append the 57 modifier.
The IP Admitting or attending physician should append the AI modifier on the initial visit for the inpatient admission. 

Instructions from Noridian on the use of the AI modifier:

Jun 8th, 2021 - Dawna 1 

re:ER/Hospitalist Professional Visits

We are using the AI modifier, however because it is the same Tax ID, we are still getting denials for 2 visits on one day. I was told by one of the insurances that a modifier should be used but they won't tell me which modifier. Are you saying that I should use 25 on the ER visit even when there is no ER procedure done and that that is the proper modifier to append to get paid for both ER visit and Admission on same date of service?  Thank you so much for your response.

Jun 8th, 2021 - ChrisW   256  1 

re: re:ER/Hospitalist Professional Visits

The 25 modifier should be used if there was other testing done in the ER.  I would suggest doing an appeal, to get it paid or at least to get in contact with the payer, it may be that the claims department is not paying attention to the taxonomy of the provider and denying it because of the NPI number.  I have seen a denial just because it was re-billed with the same information as well, that is why we are suggesting to appeal.  Without knowing all of the details it is hard to understand what is going on.  
Are you using the claim frequency codes on your claim correctly and not just re-submitting your claim? 
You should also have the option to reach out to your provider representative, I am not aware of any other modifiers than what we discussed.  I hope this helps...

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