Neurosurgery Coding Alert

Question: If our surgeon sees a patient in the office, and sends that patient immediately to the hospital, can we bill for an admission service? Or does the H&P have to be dictated at the hospital? Is an established patient office visit the better choice here?

Oklahoma Subscriber

Answer: You can report an admission code, even though the surgeon took the history and physical in the office. Because the question refers to a level-five office visit, the correct code would be 99223 (Initial hospital care -), provided the documentation supports that level of admission.

Rule of thumb: You should determine the correct E/M code by where the patient ends up (in this case, inpatient hospital), not where the surgeon dictated the report.

Warning: You should not report an office visit in addition to the admission. Stick with a single E/M code to describe this encounter.

Note, however, that if there is both clinic and hospital documentation, you may "add together" the documentation from both sites to support the highest level of service the combined documentation can support. This is key, because hospitals often require an admission note, but the surgeon might document only a brief note in the hospital after having already done a more comprehensive history and assessment in the office.