General Surgery Coding Alert

Here's how


How can you code for optimal reimbursement if the surgeon sees a patient in the emergency department (ED) and subsequently admits him or her as an inpatient? Although general coding principles prohibit reporting two E/M services on the same date of service, there is a way to receive payment based on the total effort the surgeon provides.

Report Only One E/M Code

General 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. Under most payers' guidelines (and as explicitly stated in the Medicare Carriers Manual, section 155047[G]), however, 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, according to CPT, the initial hospital care codes include any care provided elsewhere on that date: "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g., hospital emergency department, observation status in a hospital, physician's office, nursing facility) all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission."
 
You may consider the work done 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/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 are selecting among the initial hospital care codes, documentation is the key to supporting your code selection. If it isn't documented, the payer will assume it wasn't done. "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 consulting firm. When determining the MDM level, 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? Will further studies or consultations be performed?
 
3. Records and tests reviewed. How many and how complex were the tests and medical records that had to be reviewed and analyzed?

The nature of the presenting problem in the ED affects MDM, and this can carry over to the level of service chosen for the inpatient admission. For example, in the ED, the surgeon sees an automobile passenger who struck the steering wheel during a minor collision in a parking lot because he wasn't wearing a seat belt. The patient initially felt fine, and visited the hospital only at the insistence of the officer who responded to the accident. During the course of the history and physical, however, the patient begins to have shortness of breath and other symptoms. Concerned about the possibility of lung trauma, the surgeon admits the patient, orders several scans and other tests and, later that evening, must perform emergency surgery to treat a collapsed lung (518.0).
 
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 to be reviewed and diagnosis/management options to be considered, likewise increased. At the point at which 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 case, 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 no additional work beyond that involved 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 report the thoracotomy (for example, 32110, Thoracotomy, major; with control of traumatic hemorrhage and/or repair of lung tear) separately.