Inpatient Facility Coding & Compliance Alert

 Question: Do we need to report an initial hospital care code from 99221-99223 before we can bill a subsequent hospital care code for the first inpatient encounter by the admitting physician? The patient was admitted into the hospital on 11/09/12 and the initial visit was coded as a subsequent code on the admit date (with 99232). When asked about this, the coder stated that there was not enough documentation to bill an initial visit. How should we handle this?

New Mexico Subscriber

Answer: You cannot bill subsequent hospital care (99232, Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components …) for the initial visit on the admission date. If documentation supports to code at least the lowest level of initial hospital care, you can report 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components …). If you don’t have enough documentation to support 99221, you cannot code the chart. Request that the physician add an addendum to the chart so you have enough documentation for coding.