Gastroenterology Coding Alert

Question: Recently, our gastroenterologist admitted a patient to the hospital directly from the office. Should we bill just the office visit or both the office visit and the hospital admission? Our gastroenterologists also recently began performing consultations with nursing home patients. I am unclear on which CPT^® code to use.

Idaho Subscriber

Answer: Usually when you admit a patient to the hospital, you should roll everything your physician performed that day into the admission code. You can’t bill a separate hospital admission and a separate office E/M service on the same day.

In this scenario, you should report the admission and not the initial office visit beforehand. You will report the admission with initial hospital care codes (99221-99223) and not E/M codes (99201-99205, New patient office or other outpatient services …). The admitting physician (GI or another physician) is considered the “the physician of record” and has to use the initial services code with a proposed modifier AL (Physician of record). Only the admitting physician may file a claim for the initial hospital visit.

However, if the physician performs an initial consultation visit on a Medicare patient in the hospital, you should use an initial hospital code from 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components:…), 99222 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components:…), or 99223 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components:…), according to Medicare’s new consultation guidelines.

Exception: If the gastroenterologist renders a consultation in the office on Thursday and decides he should admit the patient to the hospital - he writes orders, sends in the orders, a history and a physical - he may report the in-office consultation code only if the patient is not seen in the hospital face-to-face that day. If on the following day, Friday, the gastroenterologist performs the initial hospital visit, you should report the office consultation performed on Thursday as well as Friday’s initial hospital care (99221 to 99223).

For coding nursing home consultations, you need to be sure to correctly match the appropriate CPT^® code with the place-of-service indicator for Medicare. You can use initial inpatient consult codes (99251-99255, New or established patient initial inpatient consultation services) to report physician consultations provided to residents of nursing facilities, or patients in a partial hospital setting. These codes are appropriate with a place-of-service indicator 32, which denotes an inpatient facility (specifically a nursing facility).

Some coders mistakenly use nursing facility services codes 99301-99316 for nursing home consultations. These codes are appropriate only when the physician provides ongoing care and the requirements of a consult (request, reason and response) have not been met. Note that the request for a consultation can come from any healthcare worker, including a nurse practitioner or social worker, and does not have to come directly from a physician.