Are two E/M's payable on same day by same provider?

Provider has seed the patient first in Office setting which was billed with 99213 and patient was advised to admit in hospital. Same provider has seen the patient in Hospital also which was billed with 99221/99222.

Now the payer paid for 99213 and denied 99221/99222 stating only one E/M is payable per day.
Please advise what can we do get paid for both.

Thanks in Advance.

re: Are two E/M's payable on same day by same provider?

First of all you would not bill 99221 and 99222 together. These are two levels of hospital admit. I have gotten paid for 99213 and 99221 by putting a 25 modifier on the 99221.

re: Are two E/M's payable on same day by same provider?

Please read the guidelines the CPT® book on page 16 in the 2016 Professional Edition. It states under the Initial Hospital Care;

When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service(eg, hospital emergency department, observation status in a hospital, OFFICE, nursing facility) all Evaluation and Management services provided by that physician in the conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. So if you applying a modifier 25 of an office visit to get the visit paid as the same day as the admit, you would be double dipping for the physician services and committing fraud. I would suggest that you no longer continue to do and read up in your CPT® manual and on the CMS website about the proper way to bill for an Initial Inpatient Visit and about the proper use of modifier 25.



Lisa Williams,CPC

re: Are two E/M's payable on same day by same provider?

While YOU CAN bill 2 E/M's on the same date of service in this case you should not bill both services. If the patient presented to the office and was told to go to hospital for admission and the admitting provider was the same doctor or from the same group with the same specialty you should only bill for the admission. Billing for both in that case would be fraud.

re: Are two E/M's payable on same day by same provider?

It would be appropriate to bill both if the two problems were totally unrelated. Such as the office visit for an ear ache and then the patient got hit by a car and broke a hip.

re: Are two E/M's payable on same day by same provider?

I understand that completely, but that is not how the question was asked. The provider saw the patient in a office setting and admitted the patient to the hospital for the reason he was being seen. Further more if the patient got hit by a car, I'm pretty sure he would not be seen in an office setting, the patient would go to the emergency room and if the hip required that he had surgery performed on him for the same DOS and the provider was performing the surgery, again the provider would only bill for the admit E&M level. Even if the patient was seen originally at the providers office for an earache, he could bill for that service at the time of service but if the patient then went out and got hit by an car after he left the providers office and was seen again for the broken hip and was admitted, the provider would still only bill for the admit code.

re: Are two E/M's payable on same day by same provider?

• You treat a patient in your office for an ear infection. That evening, you encounter the patient in the ED where she’s having severe asthma and admit her as an inpatient of the hospital. In this case, you could use an office visit code for the morning encounter and an initial hospital care code for the admission that evening. You would probably need to attach a -25 modifier (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the office visit code to indicate that it was unrelated to the subsequent admission. In this case, submitting different diagnosis codes would help further establish the appropriateness of coding both services.

http://www.aafp.org/fpm/2003/0200/p19.html

re: Are two E/M's payable on same day by same provider?

You can only bill the admit code, include work you did in the office eval to determine the correct level to bill.