General Surgery Coding Alert

Question: When we see a patient in the office who is immediately sent to a hospital for admission, the surgeon will dictate a history and physical (H&P) and wants us to bill for an admit. Is this allowed, or does the admit have to be dictated at the hospital, leaving us with a level-five established patient visit?

Oklahoma Subscriber  
Answer: The admit can be billed by the surgeon, but the office visit cannot. The correct E/M code is determined by where the patient ends up (in this case, inpatient hospital), not where the report was dictated. Because the question refers to a level-five office visit, the correct code would be 99223 (initial hospital care), provided the documentation supports that level of admission.   
Reader Questions and You Be the Coder answered by Elaine Elliott, CPC, a general surgery coding and reimbursement specialist in Jensen Beach, Fla.; Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill.; Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.; and M. Trayser Dunaway, MD, FACS, a general surgeon in private practice in Camden, S.C.