Podiatry Coding & Billing Alert

Question: A resident on call in the emergency room (ER) saw a patient with a broken ankle. The resident and the attending physician review and discuss the case over the phone. The physician doesn't physically evaluate the patient as an inpatient until the following day. Can I bill for that first encounter with the resident?

Georgia Subscriber

Answer: No, you cannot bill the ER visit with the resident. There has to be an attending physician in order to report a billable service.

Tip: If the resident admitted the patient and the attending physician did the rounds the next day, you can use the resident's note to support the level of service that you bill on the second day -- for example, 99221 (Initial hospital care, per day, for the evaluation and management of a patient ...). The attending physician must see the patient within 24 hours of admission for you to use this approach, however.

Example: The resident saw the patient in the ER on Monday and then admitted him the same day. The attending physician comes in and examines the patient the following day, Tuesday. You can take the resident's notes from Monday and combine it with the attending physician's notes from Tuesday. Then, report a code from the 99221-99223 series, basing the level of service on the combined notes.

-- Answers to You Be the Coder and Reader Questions were provided and/or reviewed by Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va.