Gastroenterology Coding Alert

Gastroenterologists frequently see patients in an emergency room, office or other outpatient setting and then admit them to the hospital on the same day. Both CPT and Medicare stipulate that only the initial hospital care codes (99221-99223) should be used to report any evaluation and management (E/M) services for that day. The level of care provided during these outpatient services, however, can help coders determine which initial hospital care code they should report to receive proper reimbursement.

Only One E/M Code Can Be Used

The initial inpatient hospital care codes are used only by an admitting physician to report the first hospital inpatient encounter with a patient. If the patient is seen by the gastroenterologist in another care setting on the same day as the hospital admission, the initial hospital care service is the only one that should be reported, according to Ann Zeisset, RHIT, coding practice manager for the American Health Information Management Association, a Chicago-based organization representing more than 38,000 health information management professionals.

If a gastroenterologist goes to a nursing home and identifies a need for the patient to be admitted, he or she cant bill for a nursing home visit, she explains. If the patient comes to the office and then goes to the hospital, the office staff needs to be aware that the gastroenterologist can only bill for the hospital admission.

The CPT does allow physicians to take into consideration the services provided at these other care settings when determining the level of service reported by the gastroenterologist with the initial hospital care code. The inpatient care level of service reported by the admitting physician should include the services related to the admission he or she provided in the other sites of service as well as in the inpatient setting, it states.

Dont Tally Inpatient and Outpatient E/M Times

That does not mean, however, that gastroenterologists should just add together the time spent with the patient in the outpatient and inpatient settings and use that total to determine the level of service reported. Time indicators are not the driving factors here, says Zeisset. The level of care selected should be based upon what is documented at the hospital. This goes along with the traditional documentation guideline: What is billed for must be documented.

In her experience, a gastroenterologist will take a detailed history and perform a detailed exam of the patient at the hospital, even if he or she already has done that in another outpatient setting. The gastroenterologist will document what he or she knows about that patient again in the hospital because the patients medical record at the gastroenterologists office does not become the hospital medical record, notes Zeisset. He or she will address all the history and probably do an even more detailed exam in the hospital to communicate to the hospital staff what the patient needs for treatment.

Medical Decision-Making Determines Service Level

In the hospital setting, the complexity of the history, medical examination and medical decision-making done during that initial inpatient encounter becomes the main determinate of what E/M service level is reported. Zeisset points out that the increased complexity of medical decision-making is the only difference between codes 99222 and 99223.

The level of medical decision-making is determined by the number of diagnoses and/or management options; the amount and/or complexity of medical records, tests, and/or other information that is obtained, reviewed and analyzed; and the risk of complications, morbidity, and/or mortality to the patient, explains Zeisset, who adds that the higher level of reimbursement for an initial hospital care service compensates somewhat for not being able to report multiple E/M services.

Emergency Room E/M Also Included

An E/M service performed in the emergency room also cannot be billed separately by a gastroenterologist on the same day as an initial hospital care code. The Medicare Carriers Manual states that Medicare will pay for an initial hospital care serviceif a physician sees his/her patient in the emergency room and decides to admit the person to the hospital. Do not pay for both E/M services.

Gastroenterologists still may bill for other non-E/M services performed in the emergency room in addition to the hospital inpatient codes, however, such as procedures to stop internal bleeding. Surgical procedures are a la carte or additional, says Jan Loomis, director of coding and documentation for TeamHealth West, a Pleasanton, Calif., affiliate of TeamHeath that provides emergency physician staffing to hospitals. You can still bill for any surgical pro-cedures done either in the emergency room or the hospital.

Dont Report Observation Codes Separately

Loomis also points out that observation care codes (99217-99220 and 99234-99236) cannot be reported separately on the same date as an initial hospital care code. If a patient has been in observation for several hours due to abdominal pains and then is admitted to the hospital, only one set of codes can be used unless the date changes during that period, she explains.

That one set of codes must be initial hospital care codes, according to CPT. When a patient is admitted to the hospital from observation status on the same date, the physician should report only the initial hospital care code, it states. Those codes should include the services related to the observation status services he/she provided on the same date of inpatient admissions.

Observation care codes should be used instead of the initial hospital care codes when the patient is admitted and discharged on the same day. CPT states that [f]or a patient admitted and discharged from observation or inpatient status on the same date, the services should be reported with codes 99234-99236 as appropriate.

Same Day Can Be Less Than 24 Hours

These one-E/M-service-per-day restrictions should apply only to services performed on the same date. The Medicare Carriers Manual states that Medicare will pay both visits if a patient is seen in the office on one date and admitted to the hospital on the next date, even if fewer than 24 hours has elapsed between the visit and the admission. While Zeisset says that is also part of the CPT guidelines, she adds that some payers may have different rules regarding what constitutes same day, and that gastroenterologists need to contact their payers to find out what their specific policies are.