# ED visit and admission



## Lisa Bledsoe (Sep 3, 2008)

Ok - feeling pretty stupid here.  I have a patient who was seen in the ED on 8/7 very late at night (ED doc around 9:30pm); then my doc (peds) came in around 11:00pm and at some point wrote to admit the patient.  The patient did not go to the floor until after 1:00am on 8/8/08, so according to the hospital he was not an inpatient until 8/8.  My doc then saw the patient again on 8/8 as an inpatient (pt does not go home until 8/10).  My confusion?  He did all the admit work on 8/7 and then did f/u on 8/8 but the admit date per the hospital is 8/8.  According to CPT "all e/m services provided in conjunction with the admission are considered part of the initial hospital care  when performed *on the same date as the admission*."  So what do I do with his "admit" order for 8/7 and his hospital f/u for 8/8?    Can I charge an outpatient visit for 8/7 and the initial hospital for 8/8 even though in his mind the patient was admitted on 8/7 not 8/8?


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## FTessaBartels (Sep 3, 2008)

*Actual date of service*

Hi, Lisa, 
I asked this same question of our Compliance Department a couple of months ago. They responded that the actual date on which the service was performed / the patient seen governs. To quote them "we have no control over when the hospital admitting desk finally admits the patient."  So they said if the service (initial hospital visit) was performed before midnight use that date of service on the 9922x code; any service on subsequent dates would get 9923x.

But let me throw a monkey wrench into your scenario ... if the child was so sick that the pediatrician came in at 11p to the ED ... did the care provided in the ER qualify as critical care?  If so, he can bill the 99291 code for service provided before midnight (Place of service ED), and the hospital admit code for the services provided after midnight.  Of course, he must have TWO pieces of documentation to support these two services. As an example: 
*08-30-08* Patient seen in emergency room, presenting with DKA and dehydration. Fluid resuscitation and IV insulin therapy begun. Time spent with patient in direct face-to-face critical care: 35 minutes. 
*08-31-08 *full hospital admit note meeting all the bullet points for 9922x.

By the way, even if the child is young enough to qualify for any of the NICU or PICU critical care codes, you'd bill 99291 as per CPT guidelines for critical care in an outpatient setting. 

Hope this helps. 
F Tessa Bartels, CPC, CPC-E/M


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## Lisa Bledsoe (Sep 5, 2008)

Thanks - I think I was "trying too hard"!!


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