# Initial hospital care code/Discharge code



## Trendale (Feb 24, 2009)

Hello,
Can someone explain to me when it is appropriate to use the initial hospital care codes (99221-99223) and also the hospital Discharge codes (99238-99239)? I just started coding for a PCP, I have never done E/M coding for a primary care physcian before, so as I am reading the documentation for this particular physcian, it led me to believe I should be using the codes I just mentioned above. Please read the following scenarios and tell me what you think:

1.
A patient presented to the physcian's office with SOB. Was then transferred to the  emergency room for acute MI. Patient was admitted to the ICU due to having increased troponin of 3.06. The admitting physcian is the PCP that originally seen the patient in the office.
The PCP gave me the H&P to code this scenario, I believe I should be using codes from 99221-99233. The guidelines in the CPT book reads, it is reported for the FIRST hospital inpatient encounter with the patient by the admitting physcian. ( Does this mean the physcian's initial encounter with the patient has to be in the hospital?), but then it goes on to say, when the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service, for example, PHYSCIAN'S OFFICE, all E/M services provided by that physcian in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.( So after reading this, I believed these were the appropriate codes to use) It also states any other services provided from other sites related to the admission, shoud be included.( does this mean the PCP should not charge an E/M office visit for the same day she is admitting the patient?)

Scenario 2:
Patient presented to the ER with increasing SOB. The patient was found to have bilateral pleural effusion and is being admitted to the hospital for further evaluation and treatment. The PCP gave me the H&P to code this scenario.
The PCP is the admiting physcian, I believe I should be using the initial hospital care codes ( 99221-99233) as well, as the PCP is the admitting physcian. Also two days later she discharged the patient, the documentation the PCP gave me to code for this is very minimal, as it states patient feels better, vital signs are documented, labs, impression and plan. Is this information sufficient and should I use hospital discharge service codes 99238-99239. The other description of the codes I read was if the patient was discharged on the same date.

I appreciate your assistance with both these scenarios and if you have any supporting links, that will be greatful as well. Thanks!


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## luannw7 (Feb 24, 2009)

*Hospital Admission Codes- Scenario 1*

Scenario 1
The doctor should have done an H&P again as an inpatient. Only one E&M should be submitted. It should be a high level admission code if the patient was admitted to ICU; however, the documentation needs to substantiate the 99223.


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## luannw7 (Feb 24, 2009)

*Scenario 2*

Yes, an admission code should be used 99221-99223 dependent on documentation. You should check to see if your provider dicated a discharge summary, in addition to the note. In most cases, being that 99238 and 99239 are "timed codes," start time and end time should be noted in the discharge summary. If there is no actual discharge summary, to complement the note; a subsequent visit may be submitted, possibly a 99231; again depending on documenation. Some hospitals require all discharge summaries to be dictated, and sometime the dicated summary is not available as timely as we would like. You really do want to check for that summary, as the reimbursement would be higher for the discharge code as opposed to the subsequent visit.


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## Trendale (Mar 2, 2009)

*Reply  senario 2*

Hello,
Thanks for your reply,
A discharge summary is documented, However; it is doucumented by the nurse. The start and stop time is dcoumented. Can this be used, or the provider has to document it with her signature? Thanks!


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## bigredcag (Mar 3, 2009)

nope you cannot use nurses notes. sorry


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## sgoodknight (Mar 3, 2009)

I have a similar question.

If a patient is admitted from ER at 3 a.m. by the PCP into ICU then the doctor goes back to see the patient that afternoon.  Can she bill 99221-3 and 99231-3?

When I read the CPT guidelines for Hospital Inpatient Services it just states that all other E/M services in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.

What does everybody think?  I sure appreciate everyone's thoughts.


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## ARCPC9491 (Mar 4, 2009)

One visit, per day, per provider (group) unless critical care. Now there are some exceptions, i.e. different provider specialties. 

If the patient is seen on the same calender day by the same provider, you can only bill one visit. Some allow you to combine the visits together and count it as one.


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## FTessaBartels (Mar 5, 2009)

*Original post by Letisha*

Scenario 1 ... Yes, code the appropriate admission as per documentation. HOWEVER ... you state the patient presented with SOB and was transfered to ER for acute MI and then to ICU... sounds like you may be able to code critical care 99291-92 if documentation shows: critical nature of patient's condition, critical care was provided, time of critical care is at least 30 minutes.  

Scenario 2 ... yes code the admission. Yes code the discharge code for the last day (no subsequent visit). If time isn't documented they you are stuck with 99238.  

F Tessa Bartels, CPC, CEMC


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## FTessaBartels (Mar 5, 2009)

*Reply to sgoodknight*

NO you cannot bill both an initial hospital visit and a subsequent hospital visit on the same day ....

BUT ... you say patient is admitted to ICU.  If the documentation shows the critical nature of patient's condition, that the physician was providing critical care, and time of critical care service of at least 30 minutes (you can add the time of the second visit to the time of the first visit if the patient remained critically ill) ... then you can use the critical care codes 99291-99292.  NOTE ... the time spent in providing critical care cannot be ALSO used for doing the admission ... so I'd code ONLY the critical care. 

I usually train physicians to state: "Time spent in direct face-to-face critical care, exclusive of any other procedures or service: xxx minutes"


F Tessa Bartels, CPC, CEMC


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## Trendale (Mar 9, 2009)

Hi,
Thank you so much for explaining that to me. I have an additional question regarding that. I noticed you train your doctors to say in their documentation that they did a critical E/M  and the time they spent. Is their a particular section in the H&P where they should state this?, and if they don't doucument this, I should bill the admission codes? In the physcians documentation, it did raise a flag to me when she mentioned the patient was transferred to the ER and then to ICU, However; after you expalined the use of the CC codes,I felt the HPI documentation was not sufficient to bill a critical care, as the physcian did not mention critical care or the time spent with the patient. She verbally told me how much time she spent and how difficult it was, but I told her if it was not written it never happened. I am just gathering as much information on this as I can, because I am planning on doing an in service. These are two doctors I just started coding for that transferred from a private practice to the hospital, so they may have been doing things a little different.

On the discharge summary, if the  physcian does not document the time, then I should use the 99238? 

Thanks for your help,
and all the others who replied!


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## wjensen (Mar 9, 2009)

*99238*

Yes if the physician did not state time but did dictate a discharge note you can bill the 99238. 
Wanda J.


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## ARCPC9491 (Mar 10, 2009)

On the discharge summary, if the physcian does not document the time, then I should use the 99238? 

99238 is for 30 minutes or less... so if the physician DOESN'T put a time a greater than 30 minutes, it's assumed to be less than 30 minutes and go with 99238. You don't HAVE to document "I spent 20 minutes..." etc though it's nice to do, but not required. 

For 99239- greater than 30 minutes. You always have to have the time documented to support this discharge code.


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