Neurology & Pain Management Coding Alert

Question: Our physician saw a patient in the office and decided to admit her to the hospital. He dictated an office note, then saw the patient in the hospital and dictated an admission note. How should we code this encounter?

North Dakota Subscriber

Answer: You'll select the most appropriate code from  99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...). CPT's Initial Hospital Care guidelines direct you to code the admission and include your physician's work during the office visit (or other encounter) to help determine the level of the initial hospital visit. (For the full explanation, see CPT 2009 Professional Edition, page 12, top of right column.)