We have occasional situations where a patient may be seen by two different orthopaedic providers on the same day and are wondering if there is a coding opportunity to report an E&M service for both physicians sicne they are of different subspecialties and evaluating the patient for two different medical conditions (different diagnosis). For example, on the same day, the patient will see the spine surgeon for spine care and will also see the orthopedist sub-specialist hand surgeon for a hand problem. If yes, would modifier 25 be appropriate?

First, in your question you note the hand surgeon as an “orthopedic hand surgeon” and do not indicate if s/he is credentialed as an orthopedic surgeon or hand surgeon. If s/he is credentialed as a hand surgeon (different specialty), there should be no problem in both physicians reporting their services without any modifiers and being reimbursed.
It is a reimbursement problem when two physicians of the same specialty, in the same group practice, see a patient on the same day. It should not be a reimbursement problem with two physicians of different specialties, in the same group practice, see a patient on the same day (e.g., spine surgeon and hand surgeon).

Generally payers do not recognize physician subspecialties. Therefore, they will reimburse for one E&M service per day per specialty in the same group practice. You can appeal for payment on the denied service by submitting both E&M progress notes to show that two separate services were indeed provided by two different physicians. Explain, in a cover letter, the subspecialty nature of your physicians’ expertise (e.g., fellowship training). You may try to append a modifier 25 to indicate a separate service on the same day.
Since both physicians are orthopaedic surgeons, the best option may be to combine the work of both providers and report one E&M service (potentially higher level of E&M) depending on work performed and documented and complexity of medical decision making. Both diagnoses would be appended to the one E&M. How both physicians are reimbursed for the combined service becomes a “behind the scene” allocation of revenue.

Mary LeGrand, RN, MA, CCS-P, CPC
KarenZupko & Associates, Inc.