Can you bill two ED visits for the same patient on the same day?

When are two ED visits on one day really two visits?

They are two visits when the patient left, came back and had a separate problem or a new onset. Claims Processing Manual chapter 4, section 180.4 gives the CMS example: a beneficiary goes to the emergency room twice on the same day, in the morning for a broken arm and later for chest pain. The visits are distinct and independent.

They are one visit when the patient stayed, was reassessed, or went back for the same complaint during one continuous encounter. In that case the encounter is one ED visit, and chapter 4, section 180.6 puts the line date on the date the patient entered the ER.

The chart has to show the difference, because the claims will look alike to an edit. Before releasing a second claim, look for:

• A discharge time on the first visit and a new arrival time on the second.
• A separate triage note and chief complaint for the second visit.
• Orders, results and a separate medical decision for the second visit that do not repeat the first.
• A different complaint, or a new development, rather than a recheck of the first.

How does the hospital bill the second visit?

Put the second visit on its own claim and report condition code G0 on that claim. Chapter 4, section 180.4 says hospitals under OPPS report G0 when multiple medical visits occurred the same day in the same revenue center and the visits were distinct and independent.

The Outpatient Code Editor, or OCE, enforces this. Its edit rejects multiple medical visits on the same day in the same revenue center when condition code G0 is missing. When G0 is present, each E/M line gets its own medical APC. Without it, only the line with the highest APC payment is paid and the other E/M lines are denied.

A clean pair avoids a CO-18 duplicate denial, covered below. The UB-04 revenue and condition codes page lists the fields, and the emergency medicine billing page links the code pages for the ED family.

How does the physician group bill two visits for one patient?

For Medicare, report one E/M service per date unless the problems are unrelated. Chapter 12, section 30.6.12.6 says that when more than one E/M visit is provided on the same date to the same patient by the same physician, or by physicians of the same specialty in the same group, only one E/M may be reported unless the services are for unrelated problems. The physicians should select a level representative of the combined visits.

That is why 99284 plus 99285 for one encounter is the wrong answer. 99284 and 99285 are alternative levels of the same ED service, so the claim carries the one level that reflects the whole encounter. Adding modifier 25 does not change that: chapter 12, section 30.6.6 says MACs may not permit modifier 25 to generate payment for multiple E/M services on the same day by the same physician. Modifier 25 is for an E/M on the same day as a procedure, as the modifier 25 page explains.

Two exceptions show up in ED work:

• Unrelated problems: the broken arm and the chest pain case. Chapter 12 allows more than one E/M on the date when the problems are unrelated, so the documentation has to show it.
• Critical care later in the day: both may be billed when the earlier E/M took place before the patient needed critical care, was medically necessary and had no duplicated elements. Chapter 12 requires modifier 25 on the critical care claim.

Commercial payers set their own rules for same-day E/M services. Read the payer's policy before assuming the Medicare rule applies, and check the NCCI edits page for the procedure pairs that sit alongside an ED visit.

What do you do when the second visit denies as a duplicate?

Check whether the two claims match on the fields the edit reads, then correct whichever side is wrong. CO-18 is the CARC for an exact duplicate claim or service, and the CO-18 page covers the code.

Chapter 1, section 120.2 defines an exact duplicate by fields. For an institutional claim they are the Medicare beneficiary identifier, type of bill, provider number, from and through dates, total charges and HCPCS or procedure modifiers. For a physician claim they are the identifier, provider number, from and through dates, type of service, procedure code, place of service and billed amount. A same-day second visit at the same level and charge looks identical on a physician claim.

The appeal rights differ. Chapter 1 says an exact-duplicate institutional claim is rejected and has no appeal rights, while a physician claim denied as an exact duplicate may be appealed. For suspect duplicates on physician claims, chapter 1 notes a denial based on criteria other than exact duplication can be appealed.

1. Pull both claims and compare dates, times, revenue codes, procedure codes, charges and modifiers.
2. If the visits are distinct, add condition code G0 to the second institutional claim and resubmit it.
3. If the physician claim is a true second visit for an unrelated problem, send the records for both visits with the appeal.
4. If it is one encounter, withdraw the second claim and correct the first to the combined level.
5. Do not change a charge just to get past the edit. The record is what decides.

How does Nucleus Align handle same-day ED claims?

Our hospital billing team checks bill type, revenue codes and condition codes on each institutional claim, and denials are worked within 48 hours. For the facility side, see medical coding or book a call. The first post in this series, how to bill ED observation services, covers the other same-day case.