Internal Medicine Coding Alert

Question: An internist sees a patient on rounds in the morning. The hospital staff calls the physician back to the hospital in the evening to re-examine the patient. Should I treat the second visit as a free visit?


Iowa Subscriber


Answer: No--you should code for this service. But don't use an individual code for it. Remember that the hospital initial and subsequent visits are "per day."

Instead: Combine the work from the second visit with the notes from the first encounter. Choose an E/M code that represents the work and documentation performed in both visits. Although you should report only one E/M code for the day's service, CPT and CMS do not restrict you to payment for one visit per day.

Example: In the morning, the internist performs a subsequent hospital visit for a 50-year-old male who is clinically stable and without chest pain. He performs and documents a problem-focused interval history, a problem-focused examination, and straightforward medical decision-making.

Later that day, the patient has premature ventricular contractions, and a staff member requests that the internist re-evaluate his condition. The physician performs and documents an expanded problem-focused interval history, an expanded problem-focused exam, and moderate-complexity medical decision-making.

The internist should elect a single code that covers the E/M elements from both the morning and the evening visits. Don't "double-dip" the E/M components. So if the HPI contains the same elements (i.e., location, duration, severity) in both visits, you can only count them once.

Tip: Check whether the time involved in the extra visit warrants prolonged services. For more than 30 minutes face-to-face with the patient beyond the time indicated for the chosen service level, assign prolonged inpatient physician services with +99356 (Prolonged physician service ...) and +99357 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]).

Be certain the provider documents the time spent providing face-to-face care in the progress note. For prolonged physician services without direct patient contact, consider +99358 (Prolonged evaluation and management service before and/or after direct [face-to-face] patient care ...) and +99359 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]).

Keep in mind that most payers will not reimburse for non-face-to-face prolonged services.