Pediatric Coding Alert

Get the pay you deserve for 2-day services

If you want to earn your fair share of reimbursement for office visits that result in hospital admissions, you should separately report 99201-99215 when your physician waits to see the inpatient the next day.

Physicians in group practices that rotate hospital rounds can further complicate coding for the two E/M services, says Suzanne Rushton, insurance office manager at Piedmont Health Group, a 12-physician practice with four locations in Greenwood, S.C.

For instance, a physician may see a patient in the office and admit the patient to the hospital on day one (99201-99215, Office visit for the evaluation and management of a new or established patient ...), but another physician visits the patient in the hospital and performs initial hospital care the following morning (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...), Rushton says.

To simplify the coding options and improve your E/M reimbursement, coding experts recommend that you bill based on four scenarios:

1. Office Visit Results in Hospital Admit

Suppose a 50-year-old male with chest pains presents to his physician's office. After performing a history, evaluation and medical decision-making, the physician admits the patient to the hospital as an inpatient but does not see the patient in the hospital that day.

In this case, you should report the appropriate-level office visit code (99201-99215), says Kent J. Moore, the American Academy of Family Physician's (AAFP) healthcare financing and delivery systems manager. Because the physician doesn't see the patient in the hospital on the admission date, you should use the E/M code that reflects where the physician delivered the services, he says. Since the physician performs an office visit only, you should only report that day's service.

2. Physician Performs Same-Day Related E/Ms

But when the office visit and initial hospital care occur on the same day, you should roll both services into one E/M code. For instance, a mother brings in her 18-month-old daughter, who has a high fever. Upon evaluation, the physician finds that the child has  10 percent dehydration. So, the physician sends the mother and child to the hospital with admission and intravenous infusion orders. That evening, the physician visits the patient in the hospital and checks on her progress.

In this example, you should combine the office visit and initial inpatient hospital care into one hospital E/M code (99221-99223). Because the initial hospital care's date coincides with the admission date, you should consider all related E/M services that the physician provides on that day part of the initial hospital care and submit only the initial hospital care codes, Moore says.

Moore bases his advice on CPT's passage stating that when a physician admits a patient to inpatient status during another service site encounter, you should consider all E/M services that the doctor performs with that admission to be part of the initial hospital care when performed on the same date as the admission. That means 99221-99223 encompass all of the day's related initial hospital care services, he says.

3. Initial Inpatient Care Isn't on Office Visit Date

You should, however, separately report an office visit and initial hospital care that occur on different days. Consider the following example: A physician sees an asthmatic patient in his office and admits the patient to the hospital as an inpatient. The physician doesn't see the patient in the hospital that day but visits the patient in the hospital the next morning.

In this situation, Moore recommends that you report both the office visit (99201-99215) and the hospital admit (99221-99223). Codes 99221-99223 describe initial hospital care per day, not hospital admission, Moore says. Therefore, if the physician waits until the following day to visit the patient in the hospital, you should separately report each day's E/M service.

Don't combine the office visit with the next day's initial hospital care. You should bill the appropriate initial hospital care code for the first hospital encounter between the patient and admitting physician, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.

You may have an easier time understanding  CPT's hospital care note this way: When a physician admits a patient to inpatient status during another service site encounter, you should consider all E/M services that the doctor performs with that admission to be part of the initial hospital care, as long as the physician performs the initial hospital care on the same date as the admission.

4. Different Physicians Provide Office Visit, Hospital Care

You can also apply the principles above to two physicians in the same group practice. For instance, following an in-office exam on day one, Dr. Smith, a urologist, sends a patient to the hospital with copies of his admission orders. Dr. Smith doesn't go to the hospital that day, and his partner, Dr. Jackson, sees the patient in the hospital on day two.

In this scenario, you should bill an office visit code (99201-99215) for Dr. Smith's services on day one, Moore says. For Dr. Jackson's services on day two, you should report an initial hospital care code (99221-99223), as long as the physician performs and documents the level of care necessary to bill that service. Since Dr. Smith and Dr. Jackson are in a group practice and, presumably, bill under the same group identification number, most payers will treat them as interchangeable, which allows the group to bill Dr. Jackson's service as initial hospital care, even though Dr. Smith may be the admitting physician of record.

Even if Dr. Jackson doesn't perform and document the level of care necessary to bill for initial hospital care, he may still get to report 99221, Moore says. When a physician performs a visit that meets the definition of a level-five office visit prior to the admission date and then on the admission day performs initial hospital care that involves less than a comprehensive history and physical, he should report the office visit that reflects the services he furnished and also report the lowest-level initial hospital care code (99221) for the initial hospital admission, according to the Medicare Carriers Manual section 15505.1.E.