Gastroenterology Coding Alert

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


California Subscriber

Answer: If your gastroenterologist admits the patient to inpatient status and discharges the patient on the same date of service, you should not report a separate discharge service.

According to CPT: In the situation you described, you should report only the observation or inpatient hospital care E/M codes 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 hospital services (99221-99223) and a hospital discharge (99238-99239). You should not report a separate discharge with 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date).

Example: Your gastroenterologist 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.