Orthopedic Coding Alert

You may be able to increase your E/M coding level 
 
Your orthopedic surgeon sees a patient in the emergency department (ED) and subsequently admits him as an inpatient. He can't report two E/M codes on the same date, so he has to forfeit reimbursement for the ED visit, right? Wrong.

You may be able to collect reimbursement for both services by using the physician's ED documentation to increase the inpatient E/M code level.  Report Only 1 E/M Code Orthopedists often see patients in the ED and, after examination, admit them to the hospital. The pre-admission examination can be extensive, lasting 30 minutes or more in some cases. But under most payers' guidelines (and as explicitly stated in the Medicare Carriers Manual, section 15047[G]), the surgeon can report only an initial hospital care code (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...) if the ED visit and subsequent hospital admission occur on the same day.

Look out: "You can't bill for two E/M codes on the same day. Most carriers will only pay for one service, and physicians normally choose the code that has the higher reimbursement, which is usually the inpatient E/M code," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center. Medicare and CPT Agree: Bill Only 1 E/M Problem: Medicare isn't the only source that limits your claim to one E/M code -- CPT guidelines echo Medicare's policy. "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (that is, hospital emergency department, observation status in a hospital, physician's office, nursing facility), all services that the physician provides in conjunction with that admission are part of the initial hospital care when performed on the same date as the admission," CPT states.

Solution: You can consider the physician's ED work when you select the initial hospital care code (99221-99223), says Suzan Hvizdash, BSJ, CPC, physician education specialist at the University of Pittsburgh's department of surgery.

"The inpatient-care level of service reported by the admitting physician should include the services related to the admission he or she provided in the other sites of services as well as in the inpatient setting," CPT states.

In other words, you can consider the physician's ED examination, history and medical decision-making (MDM) to select the appropriate initial hospital care code.  If You Document It, Use It When you review the initial hospital care codes, examine your physician's ED and inpatient documentation, and don't skip the MDM section. Medical decision-making is generally the deciding factor when choosing an initial care code because even the lowest-level service requires a [...]