Same Day / Same Service Policy - Reimbursement Policy - UnitedHealthcare Commercial Plans

Overview

The Same Day/Same Service Policy addresses those instances when a single code should be reported by a physician(s) or other qualified health care professional(s) for multiple medical and/or Evaluation and Management (E/M) services for a patient on a single date of service. Generally, a single E/M code should be used to report all services provided for a patient on each given day. Prolonged services and care plan oversight may be exceptions. (See UnitedHealthcare’s Prolonged Services and Care Plan Oversight policies for more information.) 

For the purpose of this policy, the Same Specialty Physician or Other Qualified Health Care Professional is defined as a physician and/or other qualified health care professional of the same group and same specialty reporting the same Federal Tax Identification number. 

Policy Codes

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  • 94002
  • 94004
  • 99201
  • 99218
  • 99222
  • 99223
  • 99232
  • 99234
  • 99236
  • 99238
  • 99239
  • 99499
* COMM-Same-Day-Service-Policy.pdf
Click to Download: Same Day / Same Service Policy - Reimbursement Policy - UnitedHealthcare Commercial Plans

Questions & Answers

Q: If a patient is seen in the office at 3:00 p.m. and admitted to the hospital at 1:00 a.m. the next day, may both the office visit and the initial hospital care be reported?

A: Yes. Because different dates are involved, both codes may be reported. The CPT states services on the same date must be rolled up into the initial hospital care code. The term "same date" does not mean a 24 hour period. Refer to the CPT book for more information.

Q: May a physician report both a hospital visit and hospital discharge day management service on the same day?

A: No. The hospital visit descriptors include the phrase "per day" meaning they include all care for a day. Codes 99238-99239 (hospital discharge day management services) are used to report services on the final day of the hospital stay. To report both the hospital visit code and the hospital discharge day management services code would be duplicative.

Q: If a patient is admitted as an inpatient and discharged on the same day, may the hospital discharge day management code be reported?

A: No. To report services for a patient who is admitted as an inpatient and discharged on the same day, use only the appropriate code for Observation or Inpatient Care Services (Including Admission and Discharge Services) as described by CPT codes 99234-99236.

Q: May a physician or separate physicians of the same group and specialty report multiple hospital visits on the same day for the same patient for unrelated problems?

A: No. The inpatient hospital visit descriptors contain the phrase “per day” which means that the code and the payment established for the code represent all services provided on that date. The physician/s should select a single code that reflects all services provided during the date of the service.

Q: In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, will UnitedHealthcare pay physician B for the second visit?

A: No. The inpatient hospital visit descriptors contain the phrase “per day” which means that the code and the payment established for the code represent all services provided on that date. The physician/s should select a single code that reflects all services provided during the date of the service.

Q: If a physician sees his patient in the emergency room and decides to admit the person to the hospital, should both services (the emergency department visit and the initial hospital visit) be reported?

A: No. When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician's office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.

Q: If a patient is seen for more than one E/M or other medical service on a single date of service, and each service is performed by a physician with a different specialty designation, but in the same group practice, would each E/M or other medical service be separately reimbursable?

A: Yes, in certain circumstances. An E/M or other medical service provided on the same date by different physicians who are in a group practice but who have different specialty designations may be separately reimbursable. The Same Day/Same Service policy applies when multiple E/M or other medical services are reported by physicians in the same group and specialty on the same date of service. In that case, only one E/M is separately reimbursable, unless the second service is for an unrelated problem and reported with modifier 25. This would not apply when one of the E/M services is a “per day” code.

Q: If a patient is seen for more than one E/M or other medical service on a single date of service, and each service is performed by a physician of the same group and specialty but with a different subspecialty designation, would each E/M or other medical service be separately reimbursable?

A: No. Subspecialty is not considered when applying reimbursement policy.