Primary Care Coding Alert

Question: The FP meets an established patient at the hospital on Monday morning for evaluation of a headache and uncontrollable jerking of the head. He admits the patient to observation at 6 a.m. and orders lab tests and a CT scan -- however, the shaking continues to worsen. The FP consults with a neurologist, who recommends hospitalization. The FP admits the patient to the hospital as an inpatient at 12:13 p.m. Monday for more examination. Notes indicate a comprehensive history and exam, along with moderate medical decision making. Should I code this as an observation? Iowa Subscriber Answer: You would not use an observation code in this situation. Instead, you would use an initial hospital care code. On the claim, report 99222 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making [...]