QUESTIONS AND ANSWERS
1 Q: If a patient is seen in the office at 3:00 p.m. and admitted to the hospital at 1:00 a.m. the next day, may both the office visit and the initial hospital care be reported?
A: Yes. Because different dates are involved, both codes may be reported. The CPT states services on the same date must be rolled up into the initial hospital care code. The term “same date” does not mean a 24 hour period. Refer to the CPT book for more information.
2 Q: May a physician report both a hospital visit and hospital discharge day management service on the same day?
A: No. The hospital visit descriptors include the phrase “per day” meaning they include all care for a day. Codes 99238-99239 (hospital discharge day management services) are used to report services on the final day of the hospital stay. To report both the hospital visit code and the hospital discharge day management services code would be duplicative.
3 Q: If a patient is admitted as an inpatient and discharged on the same day, may the hospital discharge day management code be reported?
A: No. To report services for a patient who is admitted as an inpatient and discharged on the same day, use only the appropriate code for Observation or Inpatient Care Services (Including Admission and Discharge Services) as described by CPT codes 99234-99236.
4 Q: May a physician or separate physician of the same group and specialty report multiple hospital visits on the same day for the same patient for unrelated problems?
A: No. The inpatient hospital visit descriptors contain the phrase “per day” which means that the code and the payment established for the code represent all services provided on that date. The physician(s) should select a single that reflects all services provided during the date of the service.
5 Q: In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, will Oxford pay physician B for the second visit?
A: No. The inpatient hospital visit descriptors include the phrase “per day” which means that the code and the payment established for the code represent all services provided on that date. The physician(s) should select a single code that reflects all services provided during the date of the service.
6 Q: If a physician sees his patient in the emergency room and decides to admit the person to the hospital, should both services (the emergency department visit and the initial hospital visit) be reported?
A: No. When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.
7 Q: If a patient is seen for more than one E/M or other medical service on a single date of service, and each service is performed by a physician with a different specialty designation, but in the same group practice, would each E/M or other medical service be separately reimbursable?
A: Yes, in certain circumstances. An E/M or other medical service provided on the same date by different physicians who are in a group practice but who have different specialty designations may be separately reimbursable. The Same Day/Same Service policy applies when multiple E/M or other medical services are reported by physicians in the same group and specialty on the same date of service. In that case, only one E/M is separately reimbursable, unless the second service is for an unrelated problem and reported with modifier 25. This would not apply when one of the E/M services is a “per day” code. For additional information regarding inpatient neonatal and pediatric critical care codes, CPT 99468-99480, reported by multiple physicians in the same group, see the policy titled Pediatric and Neonatal Critical and Intensive Care Services.
When the patient is admitted to inpatient hospital care for less than 8 hours on the same date, then Initial Hospital Care, from CPT code range 99221 – 99223, shall be reported by the physician. The Hospital Discharge Day Management service, CPT codes 99238 or 99239, shall not be reported for this scenario.
When a patient is admitted to inpatient initial hospital care and then discharged on a different calendar date, the physician shall report an Initial Hospital Care from CPT code range 99221 – 99223 and a Hospital Discharge Day Management service, CPT code 99238 or 99239.
When a patient has been admitted to inpatient hospital care for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date, Observation or Inpatient Hospital Care Services (Including Admission and Discharge Services), from CPT code range 99234 – 99236, shall be reported.
REIMBURSEMENT GUIDELINES for multiple e & m service on same day
The Medicare Claims Processing Manual states:
“Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. 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. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.
Contractors pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not. The inpatient hospital visit descriptors contain the phrase “per day” which means that the code and the payment established for the code represent all services provided on that date. The physician should select a code that reflects all services provided during the date of the service.
In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, contractors do not pay physician B for the second visit. The hospital visit descriptors include the phrase “per day” meaning care for the day.
If the physicians are each responsible for a different aspect of the patient’s care, pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses.”
The National Correct Coding Initiative Policy Manual states:
“Procedures should be reported with the most comprehensive CPT code that describes the services performed.
Physicians must not unbundle the services described by a HCPCS/CPT code.
A physician should not report multiple HCPCS/CPT codes when a single comprehensive HCPCS/CPT code describes these services.”
Consistent with Medicare, Oxford’s Same Day/Same Service policy recognizes physicians or other health care professionals of the same group and specialty as the same physician, physician subspecialty is not considered.
According to correct coding methodology, physicians are to select the code that accurately identifies the service(s) performed. Multiple E/M services, when reported on the same date for the same patient by the same specialty physician, will be subject to edits used by and sourced to third party authorities. As stated above, physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.
D. Documentation Requirements for Billing Observation or Inpatient Care Services (Including Admission and Discharge Services)
The physician shall satisfy the E/M documentation guidelines for admission to and discharge from inpatient observation or hospital care. In addition to meeting the documentation requirements for history, examination and medical decision making documentation in the medical record shall include:
• Documentation stating the stay for hospital treatment or observation care status involves 8 hours but less than 24 hours;
• Documentation identifying the billing physician was present and personally performed the services; and
• Documentation identifying the admission and discharge notes were written by the billing physician.