Medicare Compliance & Reimbursement

Question: Our physician saw a patient in the office, then admitted her to the hospital later the same day. Can we bill for the office visit and the first day of admission, or do we just bill for the hospital stay?

Answer: The answer depends on whether the physician sees the patient on the same day in the hospital.

Scenario 1: If the physician sees the patient in the hospital on the same day he saw her in the office, you're looking at two face-to-face visits on the same date. Report only the appropriate initial hospital care code (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...). According to CPT coding guidelines, all initial hospital care services that begin in another place of location (such as the physician's office) should be combined and coded using the appropriate level of initial hospital care. Since the 99221-99223 code will include the E/M provided in the office, you'll report an initial hospital care code that includes the work done in both sites of service; this may lead to coding a higher level of initial hospital care than if you were considering the hospital services alone.

Scenario 2: If, however, the physician does not see the patient in the hospital until the next day, bill each encounter separately. Choose the appropriate office visit code (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...) or 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) for the office visit on day one. Then add an initial hospital care code from 99221-99223 for day two, when the physician sees the patient in the hospital for the first time. Remember that CPT uses initial hospital care codes to report the first hospital inpatient encounter by the admitting physician. After that, you'll report subsequent hospital care codes, 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient . . .), until the date of discharge. When the physician discharges the patient, you'll submit the appropriate hospital discharge day code, 99238 or 99239.