Neurosurgery 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 dictated an admission note at the hospital. How should we code this encounter?

North Carolina 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 directs 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.)