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Nancy Posted Thu 29th of March, 2018 15:19:45 PM
One patient came in for two visits in the same day. The first visit was for an ear infection. Later in the day the patient came back in because she was injured. She hit her head. So these are two unrelated diagnosis. The insurance company is only paying for the first visit. When I called the ins co the Rep said to put a modifier on the E/M code. I don't know of a modifier to add to the E/M code for the second visit. What is your advice on how to handle this? You would think the ins co would want to pay for both visits. The parent would have taken the child to the ER for a much greater charge.Thank you.
SuperCoder Answered Fri 30th of March, 2018 05:49:03 AM

When a significant and separately identifiable E/M service has been provided to a patient by a same provider on the same day for an unrelated problem (i.e., head injury), the E/M service should be reported with modifier-25. It is suggested to report your second E/M visit with modifier-25


Note: You need to have two separate E/M note for both the visits. Also, the reported E/M note(s) should support all the key components required to support the level of E/M service.

  • If the patient is seen by the provider for the first time, choose from new patient visit code range (99201-99205).
  • For second visit, i.e., for head injury; use the code from the established patient code range (99211-99215), as the patient would be considered as established patient for the second visit on the same day.


If the patient is already an established patient, then code both the visits from established patient code range (99211-99215) and append modifier-25 to the second visit e/m code.

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