General Surgery Coding Alert

How can you code for optimal reimbursement if the surgeon sees a patient in the emergency department (ED) and subsequently admits him as an inpatient? Although general coding principles prohibit reporting two E/M services on the same date, you can get reimbursed for the total work the surgeon provides.

Report Only One E/M Code

Surgeons often see patients in the ED and, after examination, admit them to the hospital. The pre-admission examination can be extensive, lasting an hour or more in some cases. But under most payers' guidelines (and as explicitly stated in the Medicare Carriers Manual, section 15047[G]), the surgeon can report only an initial hospital care code (99221-99223) if the ED visit and subsequent hospital admission occur on the same day.
 
"You can't bill for two E/M codes on the same day. Most carriers will only pay for one service, and physicians generally choose the code that has the higher reimbursement. That's usually the inpatient history and physical," says Barry Haitoff, president of Medical Management Corporation of America, a billing and management firm in Brewster, N.Y.
 
And, the initial hospital care codes include any care provided elsewhere on that date, according to CPT: "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (that is, hospital emergency department, observation status in a hospital, physician's office, nursing facility), all [E/M] services that the physician provides in conjunction with that admission are part of the initial hospital care when performed on the same date as the admission."
 
But you may consider the physician's work in the emergency room when determining which level of code to use for the admission. "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 services as well as in the inpatient setting," CPT says. In other words, there is usually overlap between the ED examination and the examination, history and medical decision-making (MDM) associated with the inpatient admission, and you may therefore consider the work involved in the preadmission ED visit when selecting among the initial care codes.


If You Document It, Use It

When you select among the initial hospital care codes, documentation is the key to supporting your code selection. If you don't document a service or procedure, the payer will assume the doctor didn't do it. "Medical decision-making is generally the deciding factor when choosing an initial care code because even the lowest-level service requires a 'detailed or comprehensive' history and examination," says Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., an Atlanta-based coding and reimbursement firm. When determining the level of MDM, the physician must consider three factors:
 
1. Mortality and morbidity. What are the risks of significant complications, death or comorbidities associated with the patient's presenting problems, diagnostic procedures, and/or possible management options?
 
2. Diagnosis and management options considered. Has a definitive diagnosis been established, or are there differential diagnoses? Is the plan of care provisional, depending on further information? Will further assessment, tests, medical studies or consultations be performed?
 
3. Records and tests reviewed. How many and how complex were the tests and medical records that the physician had to review and analyze? Did the surgeon review the films or tracing himself? (Surgeon often do this but rarely document it, although it can substantially increase the level of MDM in some situations.)

The Presenting Problem Matters

The presenting problem in the ED affects MDM, and this can carry over to the level of service chosen for the inpatient admission.
 
Here's an example: In the ED, the surgeon sees a patient who struck the steering wheel because he wasn't wearing a seat belt during an auto collision. The patient initially claims to feel "fine" and protests that he only visited the hospital at the insistence of the police officer who responded to the accident. But during the history and physical, the patient begins to have abdominal pain, dizziness and nausea. Concerned about the possibility of internal injury, the surgeon admits the patient and, upon exploration, identifies a liver laceration requiring surgical repair (864.05, Injury to liver; without mention of open wound into cavity; laceration, unspecified).
 
In this case, the nature of the accident and the possibility of serious injury required a high-level history and exam. During the course of the exam, as the patient's symptoms became more apparent, the level of MDM also increased because the risk to the patient, as well as the tests the surgeon must review and the diagnosis/
management options he must consider, likewise increased. When the surgeon determines that the patient requires admission, the work involved and documented to describe the ED visit carries over to the initial inpatient care codes. You need not record a "new" history and physical.
 
In the above situation, the complexity of MDM, combined with the documented comprehensive history and exam, would likely allow you to report a level-two or -three inpatient admission with little or no additional work beyond that included in the ED visit alone.

If Surgery Follows Admission, Use -57

Be aware that if surgery immediately follows an admission to the hospital, you should append modifier -57 (Decision for surgery) to the initial inpatient E/M code to differentiate it from the usual preoperative exam included in the global surgical package. In the above example, for instance, append modifier -57 to 99223 (Initial hospital care, per day, for the evaluation and management of a patient) and separately report the liver repair (47360, Management of liver hemorrhage; complex suture of liver wound or injury, with or without hepatic artery ligation).