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Cardiology Coding Alert

Ins and Outs of Admission and Discharge Coding

Published on Tue Jan 01, 2002

Inpatient and observation admissions can be difficult to code even under the best of circumstances, but coding becomes even more complicated if the hospital admits the patient on one calendar day and the treating physician's initial encounter with the patient falls on the following calendar day.
 
This can occur, says Marko Yakovlevitch, MD, FACP, FACC, a cardiologist in private practice in Seattle, "When a patient arrives in the emergency department (ED) who is stable but still potentially at risk for an adverse coronary event and cannot be sent home directly from the ED. The patient is admitted to the care of the on-call cardiologist, who only sees the patient the next morning."
 
There are several issues to consider when coding these services, starting with a precise definition of "admission," says Gay Boughton-Barnes, CPC, MPC, CCS-P, chief medical compliance officer at the University of Oklahoma Medical Center in Tulsa. "I get a lot of questions about this issue," she says. "The word 'admission' is confusing in itself. It can mean different things to physicians, hospitals and carriers."
 
The physician's report on the date and nature of the admission may conflict with the hospital's report: 
 
  • The hospital may indicate that the patient was admitted the night before, whereas the attending cardiologist may (correctly) consider the patient admitted on the following day and bill for the initial encounter on that basis.
     
  • The place of service listed by the hospital and the physician may differ.
     
  • The physician may admit the patient to inpatient status, but the hospital lists the patient as observation.

    • The CPT manual includes three observation care codes (99218-99220) and three inpatient care codes (99221-99223). Although all six codes are clearly linked to admissions, the code descriptors refer to "initial care" and not admissions per se. In other words, Boughton-Barnes says, for the cardiologist, the date listed for the hospital admission is not the key factor in determining when the admission should be reported; rather, the date that the initial care (which requires face-to-face contact) was provided is the deciding factor.
     
    Yakovlevitch offers an example:
     
    A 65-year-old woman who had a left anterior descending stent placed three months earlier and was pain-free until a week ago starts to notice chest pain with diminishing degrees of exertion. She develops pains on Friday merely walking from her bed to the bathroom. Her husband brings her to the ED, where she is diagnosed with crescendo angina and admitted to the care of the on-call cardiologist. The patient is placed on intravenous heparin and topical nitrate therapy, aspirin, metoprolol and intravenous fluids for probable cardiac catheterization.
     
    In this situation, the cardiologist reports the appropriate level of inpatient care code (99221-99223) for his or her first visit (Saturday morning). The discharge on Sunday is billed with 99238 (hospital discharge day management; 30 minutes or less) or 99239 ( more than 30 minutes). CPT notes that 99238-99239 are for all services provided to a patient on discharge from inpatient status if the discharge is on a day other than the initial admission date.
     
    Even though the physician may have spent much time on the phone coordinating the patient's care on Friday, Boughton-Barnes says, and the cardiologist's liability began the moment the order to admit the patient was issued, the cardiologist cannot report an inpatient admission code for Friday because there was no face-to-face encounter with the patient. "Admitting a patient to the hospital should not be confused with the creation of documentation that satisfies the requirements of a hospital admission E/M service, such as 99218-99220 or 99221-99223," she says. "I advise physicians who admit patients over the phone to bill for initial patient care on the day they meet the patient face-to-face and perform a history and physical." She says the language of the "Initial Observation Care" and "Initial Hospital Care" sections of the CPT manual makes CPT's intent clear: The admission cannot be reported until the admitting physician actually sees the patient. "If physicians concentrated on how CPT describes these encounters, it would clarify the issue for them. CPT is telling them: Don't bill the service until you perform it, even if the patient has already been admitted."
     
    Similarly, the cardiologist on call may admit a partner's patient by phone without seeing the patient. In such cases, "The cardiologist who ordered the patient admitted did not provide a billable service," says Sueanne Bicknell, RHIA, CCS-P, CPC, an independent cardiology reimbursement and coding consultant in Dallas, regardless of the time and work spent coordinating care by phone because no face-to-face encounter occurred. Only the cardiologist who sees the patient (whether the same day or the next day) and provides the history, examination and medical decision-making may report the appropriate initial care code, Bicknell says. The fact that two cardiologists are involved (one admitting the patient by phone and the other seeing the patient the next morning) changes little, because carriers consider partners who share the same tax ID number to be the same physician. "Initial care codes are not for 'admit orders' but for the initial E/M services, which must consist of history, examination and medical decision-making," Bicknell says.

    Communicate With the Hospital

    Conflicts over the nature and place of service should be handled through communication with hospital personnel whenever possible. Hospitals have different policies for assigning patient status. It may help cardiologists to know their own hospital's guidelines in these matters to avoid claims being denied or returned with a request for medical records if the hospital reports an observation admission while the cardiologist bills an inpatient admit. It should be noted, however, that physicians (not hospitals) are supposed to have the last word on a patient's status. Therefore, it is even more important for the cardiologist's office to communicate the patient's status to hospital coding staff (instead of following the hospital's lead) because, ultimately, it is the cardiologist who is treating the patient and makes those decisions, Boughton-Barnes says. Shouldering that responsibility also means that cardiologists have to make sure medical-necessity requirements for inpatient admissions are met, because carriers are monitoring excessive reporting of these services when, in fact, an observation admission would have been more appropriate.

    Same-Day Admit and Discharge

    Patients are sometimes admitted to the hospital and discharged the same day. If the patient spent eight hours or more as an inpatient or in observation care, the E/M services the cardiologist provided may be reported with observation or inpatient hospital care codes 99234-99236.
     
    Note: CMS instructs physicians to satisfy the documentation requirements for both admission to and discharge from inpatient or observation care when billing 99234-99236. The time for observation care or treatment status must also be documented.
     
    If a patient is admitted to the hospital for observation with chest pain and discharged more than eight hours later on the same calendar day, for example, the cardiologist would use the appropriate code from this series depending on the level of service provided and documented. These codes are also used if the hospital admitted the patient the previous night but the treating cardiologist did not see the patient the following morning.
     
    Although cardiologists usually lose out when they admit patients by phone who stay in the hospital more than one calendar day, that is not the case with same-day admission and discharge codes, which have virtually the same value as a separate admission and discharge combined. For example, 99236 (high-level admission and discharge) has been assigned 5.93 RVUs, whereas 99220 (high-level admit to observation; 4.16 RVUs) and 99217 (observation discharge, 1.78 RVUs) total 5.94 RVUs, only 0.01 RVUs more than 99236 alone.

    If the patient spends less than eight hours in observation or inpatient status, "the physician should use initial observation care codes 99218-99220 and should not report a discharge code (99217) [observation care discharge day management]," according to Medicare guidelines published in the November 2000 Federal Register. The guidelines also state that an inpatient admission and discharge less than eight hours later on the same calendar date should be reported using only 99221-99223 and not a hospital discharge code (99238-99239).

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