Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist admitted a patient to the hospital and asked the coder to report the admit code for the service but we can’t find it. Which is the admit code?

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Answer: CPT^® does not include a code for hospital admission itself, even though physicians often document that they performed an “admit.” The admitting physician should report codes 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient …) for his care if he documents the elements contained within the codes (appropriate history, exam, and medical decision-making). He is not billing for the admission itself—he’s billing for the care for the initial hospital care that he provides, based on the documentation.

CPT^® states that the initial hospital care codes “are used to report the first hospital inpatient encounter with the patient by the admitting physician.” Physicians get paid for the care they provide, not for administrative work. Processing the admission, including dictating the required H&P, counts as administrative work, not medical care.

Note that the date of admission in the hospital record may be different from the initial hospital care that a physician provides. A patient may present through the ER late in the evening, but the attending physician may not see the patient until the next morning—so documentation of the formal admission is important when selecting the date to start reporting initial hospital care. Because 99221-99223 is not the code for the admission, it is acceptable for the initial hospital care to have a date of service on an entirely different date than when the patient is formally admitted to the hospital. The initial hospital care date of service must be the date the provider actually saw the patient and provided the service, face-to-face with the patient.

If the patient is a Medicare patient, the admitting provider should add the AI modifier (Principal physician of record) to the initial hospital care codes so that Medicare can differentiate the admitting physician from the “consultants” who are instructed by CMS to also use initial hospital care codes 99221-99223 in place of the inpatient consult codes that are no longer accepted by CMS.