Pulmonology Coding Alert

Myth: Once you discharge a patient from the hospital, any subsequent readmission counts as a new hospital stay.

Reality: If you discharge and readmit the patient on the same day, you may have to code the second E/M as subsequent hospital care, depending on the readmission reason.

Suppose a patient is admitted on March 1 and discharged on the morning of March 8. Later that day (March 8), the patient is readmitted to the hospital.

The quandary: Can you report both the discharge and a hospital care code? Should you report 99239 (Hospital discharge day management; more than 30 minutes) for the discharge and 99223 (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 high complexity) for the readmission along with documentation?

Or should you report an E/M service with 99233 (Subsequent hospital care, per day, for the evaluation andmanagement of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of high complexity), as well as the discharge code?

You can report a hospital care code in addition to the discharge code. "There are exceptions to the 'one hospital E/M per day' rule," says Joan Gilhooly, PCS, CPC, CHCC, with Health Management Resources in Salisbury, N.C.

Whether you use an admit or subsequent care code depends on the timing of the readmission, Gilhooly says.

Most physicians do not repeat a full H&P when the turn around time for re-admission (for the same problems) is less than 24 hours.

Do not feel obligated to report another initial hospital care service (99221-99223). If the physician does not feel that a full H&P is needed for the same day readmission for the same problem, he may opt to report  subsequent hospital care (99231-99233) instead, shares Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

On the other hand, if a full initial hospital care services is clinically warranted and medically necessary, report the most appropriate admission code (99221- 99223). For instance, if the patient's medications have changed from the previous admission H&P, or if the patient has resumed smoking after discharge and is experiencing exacerbations, says Pohlig, it may be necessary to document a new H&P.

You should also consider why the patient was readmitted. "If the reason for same-day readmission was related to the reason for the initial hospitalization, I'd use a code from the subsequent hospital visit series (99231-99233) and add the prolonged services code(s) (+99356 and +99357) for additional documented time spent that meets the criteria for prolonged care," Gilhooly says.

Example: A patient is hospitalized for pneumonia (486), is discharged, and is later readmitted on the discharge date with shortness of breath (786.05). The pneumonia-related shortness of breath may require a medication or therapy adjustment.

"If the patient has an exacerbation of their illness significant enough for readmission and the physician provides a status update rather than a full H&P, I would use a subsequent hospital care code possibly with a prolonged service code, assuming that the times for both encounters have been documented," according to Gilhooly.

You'd report 9923x for the discharge plus possibly +99356 or +99357 for prolonged services. "There are instances where two E/M codes (that is, 9923x and +9935x) can be billed on the same day, and this would qualify," says Suzan Berman, CPC, CEMC, CEDC, senior manager of coding and compliance with the UPMC departments of surgery and anesthesiology.

Don't forget to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the second line item.

"It may still get denied and an appeal would need to be done," Berman says.

Due to the two E/Ms, expect a payer-initiated request for documentation, then submit your encounter notes and a letter of explanation. "You don't want to give the impression that you're trying to double bill on that day," Gilhooly says

Beware: The payer may request, however, that you submit both services as a single cumulative encounter for the day, says Pohlig. When this occurs, consider the cumulative time or documentation when selecting the overall visit level.

If the pulmonologist readmitted the patient for a reason completely unrelated to the initial hospitalization, you could report a discharge code and the initial inpatient care code, Gilhooly says. Append modifier 25 to the discharge code and submit the claim.

The payer may pay both codes after the payerrequested documentation review. Alternatively, the payer may consider both services cumulatively and pay for the most appropriate admission code (99221-99223), notes Pohlig.

Example: A patient was hospitalized for pneumonia and discharged. Once home, the patient aspirates while eating the first meal, becomes acutely short of breath, and is readmitted for treatment.

These two different diagnoses (486 and 786.05) would qualify the second visit as unrelated to the first, Pohlig advises.