Miscellaneous physician Medicare coding questions to Novitas

November 19, 2018

Note: Many of these answers will apply to commercial payers as well:

If a physician sees a patient in the morning and again in the afternoon for a new or worsened condition, do we report modifier 25 for the second visit?

No, modifier 25 is used to identify a significantly, separately identifiable E/M service performed by a physician on the same date as a procedure or other service. Novitas Solutions would not expect to see two E/M services reported on the same date on a routine basis. In rare circumstances, a physician would bill a second E/M service. If a second E/M service is required on the same date of service, the documentation should clearly provide evidence that the second E/M service occurred, the reason for the additional E/M service, and documentation of the medical necessity of the second E/M service. If reporting a second E/M service on the same date, the service could initially deny. You can appeal the denial. Information on appeals is available in the Part B Appeals Reference Guide.

Can two physicians in the same group practice, who see the same patient on the same day, each bill for an E/M service and receive payment?

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. 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. Reference CMS Publication 100-04, Claims Processing Manual, Chapter 12, Section 30.6.5  

Who is expected to append the AI modifier and on which claims?

The principal physician of record will append modifier “-AI” to identify the principal physician of record, to the initial hospital care visit code when billed. This modifier will identify the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care. All other physicians who perform an initial evaluation on this patient shall bill only the E/M code for the complexity level performed. Claims which include the “-AI” modifier on codes other than the initial hospital and nursing home visit codes (i.e., subsequent care codes or outpatient codes) will not be rejected and returned to the physician or provider. Reference Medicare Learning Network (MLN) Matters Article, MM6740 – Revisions to Consultation Services Payment Policy

Can we append modifier 25 to 99211?

According to CMS, it is appropriate to append modifier -25 when the modifier indicates that a separately identifiable E/M service was performed that meets a higher complexity level of care than a service represented by 99211. Therefore, it is not appropriate to append modifier 25 to 99211.

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