Bernadette Posted Fri 27th of December, 2013 14:23:42 PM
We had a patient who came in at 3:45 pm and was examined by the pediatrician. The patient also had a nebulizer treatment and was given a dose of orapred. For this visit, We are billing a Level 5 E/M visit along with the neb treatment, pulse ox, and neb supplies. The doctor asked the patient to return at 7pm for a recheck and we are billing a Level 3 E/M for the second visit. Both visits have the same diagnosis code
519.11. Could we bill for both visits with same diagnosis code and send the documentation of both visits?
We thank you for your input..
SuperCoder Answered Tue 31st of December, 2013 01:42:51 AM
If the same doctor is seeing the patient twice in one day, you should report only one E/M code. Add the documentation for both visits together and select the appropriate code based on the total documentation of the two visits. In some cases, this may result in adding prolonged service codes to the main E/M code when coding based on time and that time exceeds the standard allotted time in the office visit codes.