Evaluation & Management (E/M) Coding Reminder: Group Practices

This article serves as an important reminder of the long standing policy for physicians in a group practice.

Remember: 

  • Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.
    • If the reason for the second visit is an unrelated problem that could not have been addressed in the first encounter, the reason for the second visit must be clearly documented in the documentation field of the electronic claim or as an attachment to the CMS 1500 Claim Form. Example: Identify when a provider is practicing in an unrecognized subspecialty (e.g., EP, retinal specialist, hand surgery, etc.) and list the diagnosis code that is unrelated to the other E/M service for the same date. If denied, you may request a redetermination including documentation so that Palmetto GBA can reconsider payment for the second visit.  
  • Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group

Providers are encouraged to view Centers for Medicare & Medicaid Services (CMS) IOM Manual, Pub 100-04 (PDF, 1.13 MB), Chapter 12, Section 30.6.5. 

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