Ophthalmology and Optometry Coding Alert

Question: Our physician saw a patient in the office, then admitted her to the hospital later the same day. Can we bill for the office visit and the first day of admission, or do we just bill for the hospital stay?

New Mexico Subscriber

Answer: The answer depends on whether the physician sees the patient on the same day in the hospital and performs an E/M service.

Scenario 1: If the physician admits and sees the patient in the hospital on the same day he saw her in the office, you're looking at work performed from two face-to-face E/M visits on the same date. Report only the appropriate initial hospital care code (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...). According to CPT® coding guidelines, all initial hospital care services that begin in another place of location (such as the physician's office) should be combined with the initial hospital workup and coded using the appropriate level of initial hospital care. Since the 99221-99223 code will include the E/M work provided in the office, you'll report an initial hospital care code that includes the work done in both sites of service.

Scenario 2: If, however, the physician does not see the patient in the hospital until the next day, bill each encounter separately. Choose the appropriate office visit code (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...) or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) for the office visit on day one. Then report an initial hospital care code from 99221-99223 for day two, when the physician sees the patient in the hospital for the first time. Be sure documentation supports the code level assignment.

Remember that for Medicare patients, the admitting physician reports the initial hospital code (99221- 99223) with modifier AI (Principal physician of record) appended. Report subsequent care with 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) and the discharge day with 99238 or 99239 (Hospital discharge day management ...). If another physician of a different specialty sees the Medicare patient during the hospital stay, he may also use the 99221-99223 code without a modifier for the initial hospital visit.