Orthopedic Coding Alert

Question: How should I bill an E/M visit in the office on the same date as a hospital admission for a Medicare patient?

New Jersey Subscriber

Answer: If the patient is seen in the office and admitted directly to the hospital, the physician should report 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ).

CPT guidelines state 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."

The level of service you report should be based on the documentation for both the office encounter and the hospital admission.