Neurology & Pain Management Coding Alert

Question: My neurologist met an established patient at the hospital on Friday morning for evaluation of a headache and uncontrollable head-shaking. The doctor admitted the patient to observation at 8 a.m. and ordered lab tests and a CT scan. The shaking continued to get worse. My neurologist admitted the patient to the hospital as an inpatient at 1 p.m. for further diagnostic testing and treatment. His notes indicate a comprehensive history and exam, along with moderate medical decision making. Should I code this as an observation?

Ohio Subscriber

Answer: Do not use an observation code in this situation -- use an initial hospital care code.

On the claim, report 99222 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity ...) for the E/M with 784.0 (Headache) and 781.0 (Abnormal involuntary movements) appended to represent the patient's symptoms. In this scenario, the patient was admitted as an inpatient to the hospital on Friday afternoon during the course of the encounter with the patient in observation status on the same date.

Per CPT 2009: When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service, all E/M services your physician provides in conjunction with that admission are part of the initial hospital care, when performed on the same date as the admission. The CPT manual states, "The inpatient care level of service reported by the admitting physician should include the services related to the admission he/she provided in the other sites of service as well as in the inpatient setting."