General Surgery Coding Alert

Question: Occasionally, the surgeon sees a patient in the office and then immediately sends the patient to the hospital for admission. The surgeon may dictate a history and physical (H&P) and direct us to bill for an admit. I have always thought that to bill an admit, the H&P had to be dictated at the hospital, and that we could only bill for an office visit (new or established patient). Is this correct?

Texas Subscriber

Answer: No. You should determine the correct E/M code by where the patient ends up, not where the examination was performed. Because the patient was admitted to the hospital, the appropriate inpatient hospital care code (99221-99223) should be reported. The same physician should not bill the two services, i.e., admission and office visit.