Billing two E&Ms on the same by the same and/or different specialties.

Hi everyone, if anyone has any information/resources on the billing the following, I would greatly appreciate it:

There are several instances where patients will make several appointments in one day (due to travel or work circumstances) and will have more than one E & M on the same day, which are not getting paid.

Example 1: Two orthopedic visits (same day with two diags) (knee specialist and shoulder specialists - not a multidisciplinary clinic).

Example 2: One primary care visit, one ortho visit, one cardiology visit.

Example 2: One primary care visit, two hemonc visits (two specialties: lung cancer specialist and pancreatic cancer specialist).

These are not getting paid and/or are hitting the "Two or more E&Ms on the same day" edits. We have tried submitting with modifiers 25 and 27 but still get denied.

Thank you,
Stacey

Multiple E/M visits/same site of service

Medicare will always look closely at multiple evaluation and management services, especially by the same provider. Medical Necessity, not patient preference, drives this choice. If it is medically necessary for a patient to be seen by the same physician on the same date of service in an office setting, there should be two separate reasons (diagnoses) for this scenario (example, seen for hypertension in the morning and then fell from ladder and sustained a concussion later in the day).
There are instances where a patient is evaluated in the office by one physician, family practitioner, and based on emergent finding, sent to a specialist to be evaluated the same day, for the acute finding. Usually Medicare will look at specialty designations for each provider and the diagnosis submitted by each. Payment will be made based on medical necessity and many times both providers will be paid. A denial can always be appealed.
Nancy

two E&Ms

Thank you Nancy, however, in the examples provided, the patient makes several appts in one day at the hosp for different specialties and therefore there are several diags that cover the medical nec. The issue is that the visits are warranted, appropriately coded with diags to support medical nec, however, they are being denied even with modifiers 25 and/or 27.

multiple E/M

First, determine "Who" is billing, the physician or the Facility (different rules)"
It is possible to bill for more than one E/M services, by multiple physicians within a single group practice, on the same date-of-service
• Medicare Claims Processing Manual, 100-04, Chapter 12, 30.6.5, Physicians in a group practice; “If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems.”
• However, this should be an exception and not the norm (two separate E/M service classes).

Diagnosis Codes (Medical Necessity)
• ICD-9 official guidelines were developed to assist both the healthcare provider and the coder in identifying those diagnoses and procedures that are to be reported.
• The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.
• The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

Facility Billing, not Physician Billing:
Billing Two Separate E/M Services
• Modifier 25 - Significant, Separately Identifiable Evaluation and Management Service by the same physician on the same day of Procedure or Other Service
• Modifier 27 – Multiple Outpatient Hospital E/M Encounters on the Same Date
– For hospital outpatient reporting purposes, utilization of hospital resources related to separate and distinct E/M encounters performed in multiple outpatient hospital settings on the same date may be reported by adding modifier 27 to each appropriate level outpatient and/or emergency department E/M code(s).
– This modifier provides a means of reporting circumstances involving evaluation and management services provided by physician(s) in more than one (multiple) outpatient hospital setting(s) (eg,hospital emergency department, clinic). Note: This modifier is not to be used for physician reporting of multiple E/M services performed by the same physician on the same date.

Facility Billing Two Separate E/M Services –Modifier 27 (not billed by physician)
Clinical Example
• Medicare patient is seen in a hospital outpatient clinic in the morning for a respiratory symptom and goes to the emergency room for an unrelated condition later in the day.
Another example is when a patient presents to the emergency room twice on the same day for unrelated visits.
• If the services are billed on a single claim, the appropriate Emergency Department E/M code and the appropriate level outpatient E/M code should be reported with modifier -27 appended. The G0 condition code should also be used to indicate that the hospital is aware that it is billing more than one clinic visit on the same day and that those encounters are unrelated; and therefore, qualify for separate reimbursement for each visit.
• For multiple claims, the hospital would bill the clinic services with the appropriate level outpatient E/M code with the modifier -27 appended, and the appropriate revenue and diagnosis code(s). Also, the hospital would bill the emergency room claim with the appropriate level emergency department E/M code, revenue code, diagnosis code(s), and other ancillary service(s) or procedure(s), as appropriate
CPT Assistant, December 2001
Communication with payor if you meet rules and are still being denied.
Nancy

Thank you

Thank you again. We have done this and have all the rules/regs and have attending all the seminars and have met with our payers and have reviewed our contracts. We will continue to bill as we are and keep appealing. Thanks again.

Multiple E/M

Nancy has covered all the bases with the rules.

The only other internal thing I'd check is to make sure each physician is signed up with the correct specialty designation.

For two E/M's by the same specialty (your Ortho example) I think you will always have to appeal these, even with a different diagnosis.

For the others, with different specialty and different diagnosis, it seems as if your MAC is processing these incorrectly. Did this start recently? Is it a longstanding problem? Whatever the answer is, this is the sequence of steps I'd take to get it solved. You can't keep appealing them, the volume will be crushing.

*Talk to a supervisor at the MAC, if you can reach someone, and have the Medicare CLaims Processing Manual citation about physicians in a group, and the CPT direction when you call, as well as multiple examples
*If you don't get help, call or email someone at the CMS Regional office. Have all of the same info available
*Listen in to the Open Door Forum that CMS holds every 6 weeks, and discuss this problem. Of course, everyone can hear your question and answer, because it's a live call. But, often, you'll be given the name of someone to call or email who will help you solve the problem.

Do any other multi-specialty group practices have trouble with these types of visits being incorrectly processed by Medicare MAC's?