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 [...]