Oncology & Hematology Coding Alert

When the oncologist admits a patient from another site of service on day 1 but doesn't see the patient in the hospital until day 2, choosing the date of service for your claim can raise some questions. Knowing the answers not only keeps your date of service accurate, but also may add to your bottom line.

Consider the following scenario offered by Dolly Cooper, CMC, and Brenda Mantia, CMC, who work with a 10-physician practice in Shreveport, La.

Scenario: The patient is admitted at 11:57 p.m., May 1, to the physician. The physician sees the patient in the hospital for the first time at 2:00 a.m. on May 2.

What would you do? Would you choose May 1 or May 2 as the date of service (DOS) for the physician's visit?

Solution: May 2 is the correct choice. The DOS for the physician's E/M is the date when the physician "provided the face-to-face inpatient encounter with the patient in the hospital," says Karna Morrow, CPC, RCC, a consultant with Coding Strategies Inc. in Powder Springs, Ga.

Support: The AMA's July 2007 CPT Assistant clarifies, "From the reporting physician's perspective, the hospital admission services (99221-99223 [Initial hospital care, per day, for the evaluation and management of a patient ...]) are reported on the day they are performed, which may not be the date of hospital admission," Morrow points out.

The key here is that so-called "admit" codes 99221- 99223 don't say anything about admission in their descriptors. They instead describe initial hospital care and require a face-to-face visit in the inpatient setting.

Bonus tip: Only the admitting physician should report 99221-99223.

The date of service for the initial hospital care is also important in determining proper coding for the oncologist's E/M services.

Initial hospital care codes 99221-99223 include all E/M services connected to a hospital admission when provided on the same date of service, Morrow says, stressing the importance of the "same date of service."

The rules: The Medicare Claims Processing Manual (Chapter 12, Section 30.6.9.1) states that "When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician's office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission."

CPT guidelines for "Initial Hospital Care" similarly instruct that "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, physician's 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."

You need to know where to locate the rules and how to apply them. Here's how the rule applies when the oncologist sees the patient (1) on the same date in the office and hospital, and (2) in the office on the first date and in the hospital on the second.

1. Same date: If the oncologist sees the patient in the office, and then admits the patient to the hospital and provides initial care on that same date, you should report only the initial hospital care code, Morrow says. You would not report the office visit.

2. Back to the two-date scenario: If the oncologist sees the patient in the office on May 1, admits the patient, and then sees the patient for the first time as an inpatient at 2:00 a.m. on May 2, you may report both the May 1 office visit and the initial hospital care on May 2, says Morrow.

So knowing to use the second date for your 99221-99223 claim allows you to be reimbursed for both an office visit and initial hospital care.

Bottom line: CPT codes 99221-99223 represent "the first hospital inpatient encounter with the patient by the admitting physician," Morrow says. That date of service may or may not correlate to the facility admission date.