Otolaryngology Coding Alert

Look to admission date when coding outpatient-to-inpatient encounters

You won't miscode encounters in which a visit or consult leads to an admission if you follow this simple rule: Always claim one E/M service per date-of-service.

When otolaryngologists provide outpatient care prior to admitting the patient to the hospital, coders aren't sure how to capture both E/M services. To make sure you don't leave any reimbursement on the table while coding preadmission encounters properly, report these services based on two guidelines:

Report 1-Day Services With a Single Code

If your otolaryngologist performs an outpatient and an inpatient service on the same day, you should combine the work from both services to determine the E/Ms.

CPT considers all services that a physician provides on the admission date part of the initial care. This includes all admission-related services that the physician provides in other sites of service, such as the hospital emergency department (ED), hospital observation status, physician's office, or nursing facility.

Result: Insurers won't pay you for two same-day E/M services. "All payers seem to follow CPT guidelines in this situation," says Rhonda Buckholtz, CPC, president of the Erie American Academy of Professional Coders chapter in Pennsylvania.

Strategy: Combine the physician's outpatient documentation with his initial hospital history and physical.

Good news: Rolling the services into one code doesn't mean you lose the preadmission work. You can capture the outpatient service with two methods:

1. If the otolaryngologist performs and documents an outpatient E/M, such as an office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...), you should include the work in the initial inpatient visit level (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...), Buckholtz says.

2. When the physician performs and documents an outpatient service that pays more than the initial hospital care, you can charge the higher-paying service instead of the admit, says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Brick, N.J.

In the above two methods, the otolaryngologist sees the patients in the hospital on the same day that the physician performs outpatient encounters. But you must change your coding when the otolaryngologist provides the services on separate calendar days.

Submit 2 Codes for Different-Day Encounters
 
When you code an outpatient service that results in the otolaryngologist admitting the patient to the hospital, you should always check the service dates. If the physician doesn't physically see the patient in the hospital on the same day that the physician performs the office visit or outpatient consultation, you should separately code each service.

Here's how:

1. Code only the office visit (99201-99215) or office consultation (99241-99245) on day one.

2. Report the initial hospital care code (99221-99223) on day two.

Common mistake: But coders sometimes report 99221-99223 whenever an otolaryngologist admits a patient from the office. "You shouldn't charge 99221-99223 on day one unless the otolaryngologist goes to the hospital and performs the visit that day," Cobuzzi says.

Why: Codes 99221-99223 represent initial hospital care, not an admittance, Cobuzzi says. "CPT doesn't contain an admit code, and 99221-99223 require the physician's presence in the hospital."