Billing Two E/M Codes Same Day, Same Specialty and Group Explained.

Is it possible to get paid for providing two separate and identifiable face-to-face evaluation and management (E/M) charges on the same calendar date that are provided by the same physician or physicians in the same speciality from the same group practice?  The answer is yes, under certain circumstances.   Just make sure the  documentation meets certain criteria.

The Centers for Medicare and Medicaid Services  reviewed a specific situation in an August 26th, 2011 claims processing transmittal titled  Clarification of Evaluation and Management Payment Policy (change request 7405) that mandates Medicare carriers to approve payment for two E/M charges in the same day by the same physician or physicians in the same specialty and group practice, under certain circumstances.

What are the circumstances for which two E/M charges will get paid in the same day?  You can find the exact text and associated explanation in the above linked pdf file under section 30.6.9 A (11 pages into the document) which describes a hospital visit and critical care on the same day.   The key to billing two E/M charges  is to provide critical care CPT® 99291 for your second face-to-face encounter.

For many hospitalist groups, signing out to cross covering physicians is part of the job.  For years I have been  paged to the bedside to provide a face-to-face evaluation on patients who have already been seen and billed for their  Initial Hospital Care  (CPT® 99221-99223) or Subsequent Hospital Care (CPT® 99231-99233)  by the physician who provided a face-to-face encounter earlier in the day.  I recommend obtaining your own 2018 AMA ®CPT manual as the definitive resource for CPT® coding.

In this transmittal linked above, CMS confirms these two sets of codes (initial and subsequent care) are "per diem" services and can only be billed once per day by the same physician or physicians in the same specialty from the same group practice.   The key to getting paid for two E/M charges in the same day  is to provide documentation in your second face-to-face encounter to show that critical care service was provided.

A lot of what I do in cross coverage for patient care is non-billable work.  If I provide 15 minutes of face-to-face evaluation, I can't bill for that service if my partner has already seen the patient earlier in the day, unless they have documented their time in their note and I meet the criteria for an add on prolonged service codes CPT® code 99356 or 99357.   I could bill for critical care if my documentation supports use of the critical care codes.  In addition, the first face-to-face initial or subsequent E/M charge could get up coded if the documentation in both encounters supports a higher level of care.  Again, 99221-99223 and 99231-99233 are per diem codes and only one physician in the same specialty and group  should submit a  CPT® code in a calendar date, regardless of whether the issues addressed by different physicians were unrelated.   Which physician you choose in  your group is up to you.  Customarily, the first face-to-face encounter gets credit for the encounter.

 How many times a month do I get called to the bedside for an acute change in mental status?  Rapid atrial fibrillation?  Hypotension?  Tachycardia?  Seizure?  Unstable vital signs?  I have never billed for these cross cover encounters or reevaluations on my own patients if the encounter lasted less than 30 minutes because nobody I work with is in the habit of documenting total time in their notes, including me.  The per diem rule applies.    Only if the visit meets criteria for critical care and it is 30 minutes or more can a second E/M charge be billed on the second face-to-face encounter.   Here is the important part of the CMS documentation.
When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical Care Services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service.  Hospital emergency department services are not paid for the same date as critical care services when provided by the same physician to the same patient. 
During critical care management of a patient those services that do not meet the level of critical care shall be reported using an inpatient hospital care service with CPT Subsequent Hospital Care using a code from CPT code range 99231 – 99233. 
Both Initial Hospital Care (CPT codes 99221 – 99223) and Subsequent Hospital Care codes are “per diem” services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice. 
Physicians and qualified nonphysician practitioners (NPPs) are advised to retain documentation for discretionary contractor review should claims be questioned for both hospital care and critical care claims. The retained documentation shall support claims for critical care when the same physician or physicians of the same specialty in a group practice report critical care services for the same patient on the same calendar date as other E/M services.
 Make sure to review all my free lectures on hospitalist E/M coding and my collection of resources for hospitalists.


EM Pocket Reference Cards Using Marshfield Clinic Point Audit

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