Pediatric Coding Alert

Question: If a pediatrician sees a patient earlier in the day at our practice, then admits the patient to the hospital later that same day and visits the patient in the early evening, can we bill for the office visit and the hospital admission, or can we only bill for one or the other?

Indiana Subscriber

Answer: In this scenario, you can only bill for the hospital admission. So, you would bill 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...) depending on whether the medical decision making (MDM) was of low, moderate, or high complexity.

Why? Per CPT^® guidelines, “when the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service ... 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.” Because of this, the guidelines go on to note that you should not report other evaluation and management (E/M) services such as 99202-99215 (Office or other outpatient visit ...) or 99381-99387 (Initial comprehensive preventive medicine evaluation and management of an individual ...) separately.

Importantly, the guidelines go on to tell you that “the inpatient care level of service reported by the admitting physician should include the services related to the admission he/she provided in the other sites of service as well as in the inpatient setting.” So, you should go back over your pediatrician’s notes for both the initial office encounter and the inpatient admission and adjust the MDM complexity level for the initial inpatient encounter accordingly.