Provider Notice Issued 05/21/2018

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Date:  May 21, 2018         

To:       Participating Advanced Practice Nurses; Local Health Departments; Physicians; and School-Based Linked Health Centers

Re:     Policy for Billing Multiple Visits and Procedures on the Same Day   

This notice serves as a reminder to practitioners of Department policy for covering multiple office or other outpatient visits and procedures on the same day. For HealthChoice Illinois managed care enrollees, providers must adhere to the applicable MCO’s claim submission guidelines.

As stated in Topic A-220.2 of the Handbook for Practitioner Services, the Department covers more than one office appointment per day when medically necessary. When a participant has multiple medical appointments on the same day, reimbursement can be made for the services of different practitioners, seeing the participant in separate sessions and for different conditions or levels of care when medically necessary. 

Example #1: A participant sees his primary care physician and later that same day sees a specialist for focused care for the same condition. The services of both may be covered when the HFS 2360 is accompanied by documentation of the medical necessity of the additional visit.

Example #2: A participant sees two practitioners on the same day for completely different diagnoses/conditions. Each practitioner is eligible for reimbursement.

Example #3: A participant sees a practitioner but returns later that same day for an unforeseen occurrence. Charges may be submitted by the same practitioner seeing a participant twice on the same day for completely different diagnoses/conditions. Both visits should be billed with a diagnosis code and office visit procedure code based on the primary reason for the visit and level of service provided. The second procedure code must be submitted with modifier 25 to indicate it was a separately identifiable E/M service. The HFS 2360 must be accompanied by the office documentation for each visit.

Per Topic A-220.2.1, a preventive medicine CPT code and an office or other outpatient evaluation and management CPT code during the same session are not separately reimbursable. The practitioner is to submit the single evaluation and management service code that best describes the actual services rendered.

Per Topic A-220.2.2, when a therapeutic procedure is performed during an office visit, reimbursement will be made for the service with the higher State maximum allowable rate, either the visit or the procedure, but not for both.

Exceptions:

1.     The evaluation and management is an initial visit.

2.     The patient’s condition required a significant, separately identifiable service above and beyond the therapeutic procedure. In such case, the E&M CPT code with modifier 25 must be submitted on the paper HFS 2360 with supporting documentation attached.

3.     Insertion, removal, or removal and reinsertion of a long-acting reversible contraceptive (LARC) is separately reimbursable from an evaluation and management service. In such case, the E&M CPT code must be submitted with modifier 25.

When a diagnostic procedure is performed during an office visit, both the procedure and the visit are separately reimbursable.

Topic A-220 and its subtopics of the Handbook for Practitioner Services provide additional guidance for other practitioner billing issues. Appendix A-1 of the handbook contains field-by-field instructions for completion of the HFS 2360 claim form. Please utilize these resources to help ensure claims are completed accurately and timely.

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565.

Felicia F. Norwood

Director