Cardiology Coding Alert

Question: My cardiologist admitted a patient to the hospital. Later that same day, he discharged the patient. Should I report two separate codes for this?

Answer: If your cardiologist admits the patient to inpatient status and discharges the patient on the same date of service, you should use a single code for both services.

According to CPT: In the situation you described, you should report only an observation/inpatient hospital care E/M code 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date), rather than initial inpatient services (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...) and a hospital discharge (99238-99239, Hospital discharge day management ...).

You should not report 99238-99239 in addition to 99234-99236 because 99234-99236 include the discharge service. Report all the E/M work provided to the patient on the date of service with a single code that reflects both admission and discharge.

Example: Your cardiologist admits a patient to inpatient status at 9 a.m. and discharges her later that day at 8 p.m.

Solution: Because the admission and discharge occur on the same date, you should report only 99234-99236, as appropriate to the documented level of service, per CPT instructions.

Note: CMS requires that the patient remain admitted for a minimum of 8 hours.