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Big Change This Fall! MUE Allows 2 E/M Codes Billed for the Same Day

  • by Margaret Klasa DC, APN BC
  • Nov 3, 2014, 12:23 PM

 Context Can Help Improve E/M and Claim Compliance with ClaimsEditor OnlineIn the past, Medicare has allowed only one Evaluation and Management (E/M) visit per day. Now, as of October 1, 2014, the Medically Unlikely Edits (MUE) allows you to report two medically necessary E/M visits per patient, per day. (Although until you receive notification from your Medicare carrier, it would be reasonable to follow existing coding guidelines.)

There are episodes when a patient sees a provider in the morning and for a different problem unrelated to the first presents later in the day. In this case the diagnoses will be different. The documentation for each visit must have every element pertaining to the E/M code clearly identified with a distinct and unrelated diagnosis.

For example...

  1. First E/M visit - the patient presents with a laceration to the palmer surface of right hand as a result of cutting up vegetables. He is assessed – wound is 3cm x 2 cm with no visible nerves or bones is evident. Wound is cleaned, 10 stitches – 5 internal stitches with dissolvable and 5 external stitches with nylon – are applied. A prescription for acetaminophen, cefadroxil, and a Tetanus shot given in the left arm. Verbal and printed patient instructions given and patient discharged to home with instructions to return in 12 days for suture removal

  2. Second E/M visit in the same day - the patient hops into the office and presents with acute left knee pain after falling over the dog. Knee is red, swollen, and tender to the touch, limited range of motion on extension to 40 degrees, positive anterior drawer sign. X-ray of left knee and crutches ordered. Physical therapy ordered. Ice with elastic wrap provided. NSAIDS prescribed with famotidine and patient instructions given to return to office in 2 weeks and plan to follow-up with orthopedic consult if needed.

The above scenario represent two distinct and separate visits as well as diagnoses. The three E/M codes that fall under the MUE release for 10/01/2014 are: 99212, 99213, and 99214 (with their respective time units).

HCPCS/CPT Code Practitioner Services MUE Values
99212 2
99213 2
99214 2

 

 

 

 

 

 Source: http://www.cms.gov/apps/ama/license.asp?file=/NationalCorrectCodInitEd/downloads/MCR_MUE_PRA_Changes.zip

Commercial payers may not follow this new Medicare MUE utilization guide. Non-Medicare payers follow the combined visit rule by instructing providers to append modifier 25 to the second indicated E/M visit if it was performed by another physician of the same specialty in the same practice. Therefore, when billing for private payers other than Medicare, consult with the payer on this new ruling.

To ensure your claims are compliant with industry changes and other payer requirements, Contexts offers our ClaimsEditor Online™ claim editing solution. Our solution contains current NCCI, clinical, and technical edits. These edits range from basic checks for accuracy of codes, appropriate use of modifiers, and validation of patient gender and age, to complex relationships such as instances of code fragmentation, utilization violations, mutually exclusive services, diagnosis/procedure relationships, and more. ClaimsEditor Online™ can be easily and seamlessly integrated into your existing billing or Electronic Health Record (EHR) process.

Want more Compliance Edge? Read this related article: CERT Program Monitors CMS FFS Improper Payments - $36 Billion in 2013

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