# ER to Inpatient



## ercoder65

If a specialist, let's say Ortho doc, see's a patient in the Emergency Room for a consult, and then admits the patient from the ER right away, is this coded as an outpatient E/M or Inpatient E/M? My Orthopedic surgeons see patients in the ER, and when they admit the patient from the ER, they code this as an inpatient consult.
I always thought that it was the location of where you evaluated the patient that determines outpatient vs. inpatient. However, I am being told that because he admitted them they are now considered Inpatients and must be coded as such. Please advise.

TIA


Richard


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## FTessaBartels

*Initial Hospital Care*

Per CPT guidelines (2009 professional edition page 12, top of 2nd column / 2010 professional edition page 14, top of 2nd column)

When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g. hospital *emergency department*, observation status in a hospital, physician's office, nusring facility) all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. (emphasis added by FTB)

So your doctors are on the right track ... it IS considered inpatient. But it is no longer a consultation. Once they make the decision to admit the patient it becomes the Initial Hospital Care code 99221-99223.  Don't forget your -57 modifier if you'll be taking patient to the OR within the next day or two.

F Tessa Bartels, CPC, CEMC


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## Jan CPC I

*Inpatient..*

I couldn't have said it better myself, inpatient it is.


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## ercoder65

Is it the same if the Orthopedic Specialist see's the patient in the ER, then the patient is admitted by the ED physician? It would still be an inpatient E/M?


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## M. Williams

No, if another service admitts the patient and the consult was rendered while the patient was still in the outpatient status (before the formal admission) then it would be an outpatient consult.


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## deyoung

*OP Consult vs. IP Consult in ER*

I am trying to understand this, so if a patient is seen in the ER and admitted:
The consultant (just a consultant, not admitting doctor) would bill an OP consult code even though the status changed to inpatient? I would think it would be an inpatient consult code since the hospital changed the status to inpatient. 

Anyone, please share your thoughts. 

Thanks!


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## LTibbetts

Donna, actually, as I understand it, if a patient was consulted in the ER, and the patient is then admitted to inpatient status (not OBS) by the attending physician (not the consulting physician), the attending charges the initial inpatient code with AI modifer and the consulting doc would also charge an initial inpatient visit with no modifier, unless a surgery was planned. If the patient had a consult in the ER but was then discharged, then the consulting doc would charge an ER visit.

If pt was admitted to OBS but had a consult while still in the ER, then the consulting doc would charge a new office visit, if they have never seen that patient. If they have seen this particular patient before, then it would be an est patient visit that they would use for the consult. Hope this helps. I know the new consulting codes are confusing. These rules only apply to Medicare patients, however. Some payers may also change their consulting coding guidelines, so you might want to check with them first before billing consults.


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## asasands

*Coder*

I am still a little confused.  I was at a coding meeting last week.  I asked one of the panel members this exact same question.  This was her response:"If your doctor consulted the patient in the ER and did not admit the patient, you code it as an outpatient consult regardless if the patient is made an inpatient."  I asked how come it wouldn't be an ER consult and she said the ER physician would use that code.

So now there is conflicting information on this board.  Any more suggestions?

Thanks


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## deyoung

Hi Leslie,

Thank you for the info. I am mainly wondering about non-Medicare patients; anyone?

Thanks!


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## RebeccaWoodward*

asasands said:


> I am still a little confused.  I was at a coding meeting last week.  I asked one of the panel members this exact same question.  This was her response:"If your doctor consulted the patient in the ER and did not admit the patient, you code it as an outpatient consult regardless if the patient is made an inpatient."  I asked how come it wouldn't be an ER consult and she said the ER physician would use that code.
> 
> So now there is conflicting information on this board.  Any more suggestions?
> 
> Thanks



The panel member needs to refer to this Medicare guideline....

*F. Emergency Department Physician Requests Another Physician to See the Patient in Emergency Department or Office/Outpatient Setting*

If the emergency department physician requests that another physician evaluate a given patient, the *other physician should bill an emergency department visit code.* If the patient is admitted to the hospital *by the second physician performing the evaluation*, he or she should bill an initial hospital care code and *not* an emergency department visit code. (Medicare Chpt 12)

If this is a NON-Medicare and the carrier still recognizes the consultation codes and the requirements for a consultation are met (assuming an opinion was being sought) , you could bill from 99241-99245.


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## LTibbetts

deyoung said:


> I am trying to understand this, so if a patient is seen in the ER and admitted:
> The consultant (just a consultant, not admitting doctor) would bill an OP consult code even though the status changed to inpatient? I would think it would be an inpatient consult code since the hospital changed the status to inpatient.
> 
> Anyone, please share your thoughts.
> 
> Thanks!



I think that it would depend on whether or note the consult was done before or after the admit. If done before, then as Rebecca states above, the criteria for o/p consult codes have been met and you would use those. Inpatient consults would be for a consult in the inpatient setting, after the patient has been admitted. Is that what you mean?


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## deyoung

Hi Leslie,

Thanks, so, for example (non-Medicare): patient is seen by consultant in ER on 03/02/10, another doctor admits the patient on 03/02/10, the hospital changes the status to inpatient admission date of 03/02/10 (i.e., patient was admitted from ER and is an inpatient from 03/02/10 to 03/05/10), consultant would bill from the outpatient consult series 9924x? 

Thanks!


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## cchodg

Yes, as long as that payor accepts the consult codes.



deyoung said:


> Hi Leslie,
> 
> Thanks, so, for example (non-Medicare): patient is seen by consultant in ER on 03/02/10, another doctor admits the patient on 03/02/10, the hospital changes the status to inpatient admission date of 03/02/10 (i.e., patient was admitted from ER and is an inpatient from 03/02/10 to 03/05/10), consultant would bill from the outpatient consult series 9924x?
> 
> Thanks!


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## ewilliams941@gmail.com

*100% agree*



LTibbetts said:


> Donna, actually, as I understand it, if a patient was consulted in the ER, and the patient is then admitted to inpatient status (not OBS) by the attending physician (not the consulting physician), the attending charges the initial inpatient code with AI modifer and the consulting doc would also charge an initial inpatient visit with no modifier, unless a surgery was planned. If the patient had a consult in the ER but was then discharged, then the consulting doc would charge an ER visit.
> 
> If pt was admitted to OBS but had a consult while still in the ER, then the consulting doc would charge a new office visit, if they have never seen that patient. If they have seen this particular patient before, then it would be an est patient visit that they would use for the consult. Hope this helps. I know the new consulting codes are confusing. These rules only apply to Medicare patients, however. Some payers may also change their consulting coding guidelines, so you might want to check with them first before billing consults.




Just wanted to mention I agree 100% with the above note from LTibbetts. I code for Gastroenterologists who consult the ER/Hospital, and this is exactly how we code. We are never the admitting doctor so we never need the AI modifier, but once that patient turns IP, we code as IP.

And agreed the consulting codes are quite confusing as they vary by payer from 99201-99205 (initial new pt), 99211-99215 (initial estab. pt/ subsq. new or estab. pt), 99241-99245 (initial) and 99224-99226 (susq.). -- Also note, if your doctor is NOT the admitting doctor you should not be using 99218-99219 (only used for those physicians who are designating the pt to OBS status)

Good luck to all coding!


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