Pediatric Coding Alert

Question: Pediatrician A treats a patient in the office in the morning. Pediatrician B, who is a hospitalist and uses the same tax identification number as Pediatrician A, admits the child to the hospital later the same day. Should Pediatrician A code his E/M (and procedures, if any) with symptoms as his diagnosis, and Pediatrician B code the hospital admit for the same day with the diagnosis? Or should I submit one daily E/M code?


Washington Subscriber

Answer: You should combine the two E/M services into one admission code. Because the pediatricians are in the same group practice, you should follow CPT's hospital inpatient coding guideline. "All evaluation and management services provided by the admitting physician in conjunction with the admission, regardless of the site of the encounter, are included in the initial hospital care service. Service provided in the emergency room, observation room, physician's office, or nursing facility specifically related to the admission cannot be reported separately," states CPT's Hospital Inpatient Services' introductory notes. Therefore, you would combine the work involved in the office visit in the admission code that you select.

Because the two pediatricians use the same tax ID number, insurers will view the same-day encounters as coming from one group. Translation: If you instead submitted two E/M codes, the payer would reject the second claim as a duplicate service.

Watch out: You should only combine the two E/M services provided the hospitalist sees the patient on the same calendar day that the pediatrician performs the office visit. Otherwise, charge an outpatient office visit (such as 99212-99213, Office or other outpatient visit for an established patient ...) on day one and an initial hospital visit (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...) on day two when the hospitalist provides his initial face-to-face inpatient service.

Exception: If, however, the two physicians were in different specialties or board-certified subspecialties, you should separately report each service. For instance, Pediatrician A performs an office visit on a newborn for jaundice and a neonatologist later admits the infant for inpatient treatment. Because neonatology is its own subspecialty, you should report each E/M service--such as 99222 and 99213-99214 appended with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or another service)--with a diagnosis of neonatal hyperbilirubinemia (774.6, Unspecified fetal and neonatal jaundice).

Pediatric hospitalists, however, are not considered a separate specialty from pediatrics. "The hospitalist movement lacks two fundamental characteristics of a specialty," said Dr. Mark A. Kelly. "There is no unique medical knowledge or skill required and therefore no requirement for advanced training," remarked Kelly at a meeting on the emerging role of hospitalists sponsored by the University of California, San Francisco. Hospitalists simply provide more inpatient care than generalists.