Part B Insider (Multispecialty) Coding Alert

Tip: Find out the reason for readmission before you code.

Myth: Once you discharge a patient from the hospital, any subsequent readmission counts as a new hospital stay.

Reality: If you discharge the patient and readmit her on the same day, you may have to bill a subsequent hospital care code, depending on the reason for readmission.

The scenario: Suppose a patient is admitted on March 1 and discharged on the morning of March 8. Later that day (March 8), the patient is readmitted to the hospital.

The quandary: What is the appropriate way to code the charges? Should you report 99239 (Hospital discharge day management) for the discharge and 99223 (Initial hospital care, per day) for the readmission along with documentation? Or should you report an E/M service with 99233 (Subsequent hospital care, per day)?

Solution: There are exceptions to the one hospital E/M per day rule, says Joan Gilhooly, PCS,CPC, CHCC, with Health Management Resources in Salisbury, N.C.The solution is going to depend on the reason for the readmission.

Avoid this: You should not report 99223. Since the doctor has been providing ongoing care for the previous 10 days, I dont think you can justify taking a complete past family social history (PFSH again) if a complete history was taken just seven days before, Gilhooly says. In this case, the most the physician would be able to charge for the second initial hospital care is 99221,Gilhooly says.

Determine Reason for Readmit

Your first step in accurately coding this case is finding out why the patient was readmitted.

If the reason for readmission was related to the reason for the initial hospitalization, Id use a code from the subsequent hospital visit series (99231-99233) and add the prolonged services code(s) for additional time spent, Gilhooly says.

For example: A patient is hospitalized for pneumonia, is discharged, and is readmitted later on the discharge date with shortness of breath. The shortness of breath is related to the pneumonia, but if the patient has an exacerbation of their illness significant enough for readmission, I would use a subsequent hospital care code with a prolonged service code, assuming that the times for both encounters has been documented, Gilhooly says.

Tip: In this scenario, submit your claim along with encounter notes and a letter of explanation.You dont want to give the impressionthat youre trying to double bill on that day, Gilhooly says. Just submitting the claim would trigger an automatic denial, so right off the bat, send it in on paper with notes and a letter of explanation.

Remember: Dont forget to append modifier 25 (Significant,separately identifiable E/M on the day of the procedure) to the second line item. It may still get denied and an appeal would need to be done, says Suzan Berman-Hvizdash, CPC, CEMC, CEDC, senior manager of coding and compliance with the UPMC departments of surgery and anesthesiology.

Remember: There are instances where two E/M codes can be billed on the same day, and this would qualify, Hvizdash says.

Alternative: If the physician readmitted the patient for a reason completely unrelated to the initial hospitalization, you could report a discharge code and the initial inpatient care code, Gilhooly says. Append modifier 25 to the discharge code and submit the claim with a cover letter and notes that explain why the two unrelated services were provided in the same calendar day.

Example: Suppose the patient was hospitalized for pneumonia and discharged. Once home, the patient falls down the stairs, incurring an injury that requires her to be readmitted for treatment of the injuries. These two different diagnoses would qualify the second visit as unrelated to the first, Gilhooly advises.