Internal Medicine Coding Alert

Internists frequently see patients in settings other than their office: Nursing home examinations, hospital visits and, sometimes, house calls can all be part of the internal medicine practice. The most frequent out-of-office service occurs when the internist has a patient admitted to the hospital through the emergency department (ED). These visits can be the most confusing to code because they often involve obtaining information not only from your internist but also from the hospital information personnel and, perhaps, other physicians who saw the patient.

Frequently, an internist who is a patients primary care provider (PCP) will be asked to come to the hospital ED to examine his or her patients and determine whether they should be admitted. In this case, the ED physician may be the first provider to examine the patient, with the internist called to assume care for the patient and/or admit him or her. The challenge is usually this: What code should the internist report for the service provided, and what code should be reported by the ED physician?

Patient is Admitted by the PCP

If the patient is admitted by the internist, the internist should report a code for initial hospital care (99221-99223), depending on the level of service performed and the extent of the documentation of the visit, says Peggy Breiner, CCS, CPC, senior consultant for education and training in the Compliance, Coding and Education Division of QuadraMed Corporation, a nationwide healthcare information technology firm based in Richmond, CA. The reporting guidelines for hospital inpatient services indicate that, when a patient is admitted to the hospital as an inpatient during an encounter in another site of servicein this case the EDall evaluation and management (E/M) services performed by the admitting physician in conjunction with the admission are considered part of the initial hospital care.

This means that any services related to that medical problem performed by the PCP for that patient on that day are also included in the initial inpatient hospital code, says Dea Genth, practice coordinator for Inpatient Medicine Service, a group of physicians in Englewood, CO. Any service performed by the PCP that day, up to admitting the patient, would be included in 99221-99223, she says.

For example, a patient presents to the internist in the morning with severe chest pain. The internist evaluates the patient and sends him to the hospital to be admitted for tests, then the office visit and hospital admission are bundled into the inpatient admission.

ED Physician Examines Patient, Calls PCP

What if a patient presents unexpectedly to the ED and is examined by the ED physician, who then calls the patients internist?

For example, a woman with an asthma exacerbation comes into the ED with difficulty breathing. The ED physician performs an initial evaluation, stabilizes the patient, and calls her internist, who comes to the ED to assume care of the woman.

The ED physician that saw the patient initially before calling the PCP should report the appropriate emergency department service codes (99281-99285) for the level of service performed, reports Gerth.

If the internist decides to admit the patient, then the internist should report the initial inpatient admission. If the internist treats the patient in the ED and the patient is released, the internist should report an office/outpatient code (99211-99215) to indicate the level of service provided.

Confusion Over Internist Reporting E/M Codes

In the December 1998 issue of Internal Medicine Coding Alert, one source advised reporting consult codes (99241-99245) when internists see patients in the ED at the request of the ED physician.

However, this would be incorrect if the internist assumed responsibility for the care of the patient. A consult code can be reported only if the consulting physician provided an opinion to the treating physician and the treating physician remained in charge of the patients care.

Specialists are often called to the ED to consult on a particular patients treatment. But, an internist coming in to assume treatment of a patient he or she regularly sees does not qualify as a consult.

Some internal medicine practices report services provided by their physicians to their patients in the ED with the emergency service E/M codes (99281-99285). The RVUs for these codes are higher than those of the office/outpatient E/M codes, in most part to reflect the added expense and higher level of acuity required in this setting.

If the ED physician sees the patient initially, most coding consultants feel that the ED doctor should report an emergency service E/M code, with the internist reporting an office/outpatient E/M code.

CPT states that the office/outpatient E/M levels are for office or other outpatient services, which makes them appropriate for other sites of service as well.

Reporting Admission When Internist Sees Patient One Day After ED Physician

In some cases a patient presents to the ED with a complication of an existing medical problem that is being treated by the internist. The ED physician examines the patient and calls the internist (the patients PCP) to report the patients condition. The PCP orders
the patients admission and gives instructions for the start of treatment.

However, the PCP is unable to come to the hospital to perform his initial workup and write treatment orders until the next morning. How should this service be reported?

The ED physician should again report the appropriate level of emergency department care (99281-99285), advises Breiner. ED physicians do not normally admit patients to the hospitalthey do not have admitting privileges. In this case, the ED physician admitted the patient on the advice of the PCP. The order in the medical record most likely states, admit to the service of Dr. ____. The PCP should report the appropriate level of initial hospital care (99221- 99223) for the service provided the following day.

The reporting guidelines in the CPT manual clarify that the initial hospital care codes are used to describe the first hospital inpatient encounter with the patient by the admitting physician.