General Surgery Coding Alert

Case study shows you the difference between office visits and admissions

A hospital admission requires face-to-face service. So what should you do if the surgeon who -admits- the patient isn't present when the patient arrives at the hospital? Read the following case study to find out.

Case study: The surgeon sees a patient in the office. During the visit, the surgeon decides to admit the patient to the hospital directly. The physician dictates the history and physical (H&P) over the phone to the hospital and sends the patient over to the hospital. But the initial face-to-face interaction in the hospital setting doesn't happen until the next day.

Dates Must Correspond

Solution: If your surgeon admits a patient to the hospital from his office but the physician doesn't see the patient in the hospital that day (performing history, exam and medical decision-making face-to-face the following day), you should report the office visit on the date the physician saw the patient in the office and then bill an initial in-hospital code (99221-CPT 99223 , Initial hospital care, per day, for the evaluation and management of a patient -) the next day.

Here's why: The date of admission to the hospital and the first hospital visit by the physician will not correspond, but this is the proper coding for your scenario. The first day the physician sees the patient in the hospital becomes the initial hospital admission, not the actual day of admission.

-Codes 99221-99223 are not admit codes -- even though we often call them that,- says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. -They are described as initial hospital care and do not necessarily have to correlate to the admit date.-

When your physician performs an E/M service in the office and then admits the patient to the hospital and visits him at the hospital on that same day, the proper coding limits the provider to only one E/M per day. So he would bill only an initial inpatient code (99221-99223) with no billing or payment for the office service. You will not be paid for both an office visit and a hospital initial inpatient visit on the same day.

Patient Status, POS Matter

You should report an office visit based on whether the patient is a new patient or established patient. For the visit on the second day, choose the appropriate code from 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) based on the level of service the physician provided.

Tip: When you use an inpatient care code, you must report the corresponding place of service (POS) code 21 (Inpatient hospital). The POS code on your claim should always be consistent with the site of service indicated in the codes you report. As stated, you cannot bill or be paid for both a hospital admission and an office visit on the same day because the initial hospital inpatient care codes (99221-99223) include all the physician's services on that date whether performed in the office, emergency department or in-hospital.

Therefore, you should combine all the physician's work and documentation on that one day to determine the appropriate-level initial inpatient care code to cover the office visit, admission services and other nonsurgical treatment that day, says Morgan Hause, CCS, CCS-P, privacy and compliance officer for a multispecialty practice in Indianapolis.