General Surgery Coding Alert

Reader Questions:

Count Readmission as Separate Service

Question: The surgeon discharges a patient and readmits him to the same hospital the next day. Should I code for a second admission service?


Maryland Subscriber


Answer: Yes. You should report the admission with 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient -). A discharge service (99238-99239, Hospital discharge day management -) ends any hospital stay, making a subsequent admission on a following service date appropriate.

Key: The surgeon must provide a complete history and physical on the admission date to qualify for 99221-99223. Choose the appropriate E/M level based on the key components of a history, exam and medical decision-making that the physician performs and documents. 

Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.

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