Neurosurgery Coding Alert

Its common for neurosurgeons to see patients in the emergency room (ER) and subsequently admit them as inpatients. The ER visits that precede hospitalizations can be extensive, even hours long. In general, however, a neurosurgeon will be reimbursed only for either the ER visit or hospital admission, if they both occur on the same day.

You cant bill for two evaluation and management (E/M) codes on the same day. Most carriers will only pay for one, so most practices choose the code that has the higher reimbursement. Thats usually the inpatient history and physical, explains Barry Haitoff, president of Medical Management Corporation of America, a billing and management firm in Brewster, N.Y.

According to CPT 2000, the initial hospital care codes (99221-99223) include any care provided elsewhere on that date: When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g., hospital emergency department, observation status in a hospital, physicians office, nursing facility) all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.

It is appropriate, however, to consider the work done in the emergency room when determining which level code to use for the admission. As CPT 2000 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 services as well as in the inpatient setting.

There is usually overlap between the ER examination and the examination, history and decision-making associated with the inpatient admission. When a neurosurgeon goes to the ER, much of the work done there ties into what they need for the hospital admission, says Gail Levy, a consultant with ADB Associates, a healthcare reimbursement consulting firm based in Baltimore.

Knowing Which Inpatient Codes to Use

Which of the three hospital care codes 99221, 99222 or 99223 is appropriate, then? (See Inpatient Hospital Care Codes, page 47.)

Medical decision-making is what drives the difference between the hospital care codes, because even the lowest-level code requires a detailed or comprehensive history and examination, explains Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., an Atlanta-based coding and reimbursement firm.

The three elements of medical decision-making include:

1. Mortality and morbidity. What are the risks of significant complications, death, or comorbidities associated with the patients presenting problems, diagnostic procedures and/or possible management options?

2. Diagnosis and management options considered. Has a definitive diagnosis been established, or are there differential diagnoses? Will further studies or consultations be performed?

3. Records and tests reviewed. How many and how complex were the tests and medical records that [...]