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 of moderate complexity &) for the E/M with 784.0 (Headache) and 781.0 (Abnormal involuntary movements) appended to represent the patients symptoms. In your scenario, the patient was admitted as an inpatient to the hospital on Monday afternoon during the course of the encounter with the patient in observation status on the same date.

Per CPT 2009: When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service & all 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.

-- Information for and answers to You Be the Coder and Reader Questions reviewed by Kent Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians in Leawood, Kan.