Neurosurgery Coding Alert

Question: Our neurosurgeon treated a patient in the ED who had a severe headache and facial pain after losing control of his motorcycle and crashing. Notes indicate the surgeon performed a comprehensive history and exam with moderate medical decision-making -- but I am not sure what type of E/M this is. Does this scenario qualify as a hospital admission, or is it a subsequent hospital care encounter?


West Virginia Subscriber
Answer: It depends on whether or not your neurosurgeon assumed total care for the patient after the E/M. You can report a hospital admission code if your neurosurgeon assumes complete responsibility for the patient's care.

So if the patient stayed under your surgeon's care after the E/M, you should:

- report 99222 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity) for the E/M service.

- attach 784.0 (Headache) to 99222 to represent the patient's head injury.

- attach E816.2 (Motor vehicle traffic accident due to loss of control, without collision on the highway; motorcyclist) to 99222 to represent the accident that caused the patient's injury. However, if another physician admitted the patient after the neurosurgeon's E/M, you should:

- report 99244 (Office consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity) for the E/M service.

- attach 784.0 to 99244 to represent the patient's head injury.

- attach E816.2 to 99244 to represent the accident that caused the patient's injury.