Eli's Rehab Report

Question: I was recently called into the hospital to take over the care of a stroke patient who was unable to get along with her previous physiatrist. I began my care three days into her eight-day hospital stay. How should I code for my first inpatient visit with her?

Illinois Subscriber

Answer: CPT states that the initial hospital care codes "are used to report the first hospital inpatient encounter with the patient by the admitting physician. For initial inpatient encounters by physicians other than the admitting physician, see initial inpatient consultation codes (99251-99255) or subsequent hospital care codes (99231-99233) as appropriate." 
 
In your case, it sounds as if you were not performing a consultation, so you would use one of the subsequent hospital care codes. These codes represent both new and established inpatient visits, so even if you have never met the patient before, you would still bill the 99231-99233 series.

 - You Be the Coder and Reader Questions were reviewed by Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center.