COMPLIANCE FOCUS
Clarification on Same Day Visits
Medicare has clarified certain aspects of the definition of “new patient,” “Office/Outpatient E/M Visits Provided on Same Day for Unrelated Problems” and “Drug Administration Services and E/M Visits Billed on Same Day of Service.”
Since October, “new patient” means a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the last three years. For example, if a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, such as reading an X-ray or EKG, in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.
In addition, except where specifically noted, carriers may not pay two E/M office visits billed by a physician or physician of the same specialty from the same group practice for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office or outpatient setting which could not be provided during the same encounter.
Medicare also has advised physicians that CPT code 99211, which denotes the lowest of five levels of service provided to an established patient, cannot be paid if it is billed with a drug administration service such as a chemotherapy or nonchemotherapy drug infusion code and/or a therapeutic or diagnostic injection code. Therefore, when a medically necessary, significant and separately identifiable E/M service is performed, in addition to one of these drug administration services, the appropriate E/M CPT code should be reported with modifier -25. Documentation must support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required.
Editing for these changes were implemented in the Medicare claims processing system in January. These changes are reflected in Change Request 4032. To view the document in its entirety please visit: www.cms.hhs.gov/manuals/pm_trans/R731CP.pdf
Questions? Contact Neil Walsh at ext. 2-9377 or cwalsh6@partners.org