Internal Medicine Coding Alert

Question: The hospital asked my on-call internist to admit a patient. He spent one hour with the patient at the hospital but decided not to admit her. Normally, he sends patients from our office to the hospital and I report an outpatient and E/M code. Should I use emergency department services codes instead, because the hospital contacted the internist?

Montana Subscriber

Answer: Yes, but rule out the possibility that the emergency department visit qualified as a consult.
 
What to look for: If your internist took over the patient's care from the ED physician, you can bill the appropriate ED services code (99281-99285) for any treatment your internist rendered to the patient. You need to account for only the services your internist provided, not the ED physician's treatment prior to the internist's arrival at the hospital.
 
Remember: You cannot use initial hospital care codes (99221-99223) or subsequent hospital care codes (99231-99233) because neither the internist nor the ED physician admitted the patient to the hospital.
 
Pitfall: If the ED physician called your internist into the hospital to provide a consultation and your internist did not take over the patient's care, you should report an outpatient consultation code (99241-99245). Important: You must have proper documentation that supports the consultation claim in the patient's chart.

 - Answers for You Be the Coder and Reader Questions were reviewed by Kathy Pride, CPC, CCS-P, a coding consultant for QuadraMed in Port St. Lucie, Fla.; and Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise.