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May 30th, 2018 - sschwartz 3 

Office visit with Provider and Nurse Only lab, same DOS

Am having an issue at our clinic where a patient will come in for an office visit with one provider to deal with heal issues, but then reception is scheduling a separate appointment on the same day for an INR or Venipuncture as a Nurse Only due to the lab order being initially by another provider of our group who had monthly lab draws scheduled in advance. This created two separate encounters and two claims. As far as I know most insurances won't pay for two claims on the same DOS unless one is a specialist and it is a different diagnosis. Also we are a rural health clinic and can only bill one ENC to MC and MCD. Is there a reason the lab draw can't be combined on the visit with the E&M? Or due to it's being initially ordered by another provider in our group does it have to be on a separate claim?

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Jun 14th, 2018 - ChrisW   91  1 

re: Office visit with Provider and Nurse Only lab, same DOS

Per CMS, two office visits for the same Patient, same provider, same specialty, same group is not payable. You can, however, bill a separate service if the problem is unrelated. Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.

The diagnosis should be different with each treating provider, in other words, the service is for a different reason than the provider doing the E/M. If these were two totally different procedures performed by different providers, you need to bill two procedures.

CMS PUB-10-04 Claims processing manual – transmittal 3315

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