Advanced Search

Urology Coding Alert

Location, Time, Days Determine Admission-Discharge Status

Published on Fri Mar 01, 2002

When a patient is admitted and discharged on the same day, consider the place of admission or observation, time spent in the facility, and calendar day(s) involved. Following are examples that may be encountered in everyday urological practice, according to Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York, Stony Brook.

Same-Day Inpatient Admission and Discharge
 
A patient is admitted to a hospital at 6 a.m. because of severe renal colic (788.0). He passes a calculus at 5 p.m. and is completely asymptomatic and afebrile. The urologist discharges him after evening rounds at 8 p.m. The patients stay in the hospital is 14 hours. Use same-day hospital admission and discharge codes (99234-99236) for a stay of eight hours or more, but less than 24 hours.
 
At 8 a.m. a 70-year-old patient is admitted to the urological service because of severe testicular pain. At 8:30 a.m. a testicular ultrasound reveals epididymitis (604.90, Other orchitis, epididymitis, and epididymo-orchitis, without mention of abscess; unspecified), and antibiotics are started. The patient rapidly improves and desires immediate discharge. He is discharged at noon on antibiotics. Because his hospital stay is less than eight hours, report the hospital admission (99221-99223) only. Do not also bill a discharge code.
 
Note: The eight-hour rule for 99234-99236 applies to Medicare only, not to commercial payers, explains Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. For commercial payers, use 99234-99236 for same-day admission and discharge including stays of less than eight hours.
 
If the urologist performs a procedure during a same-day admission and discharge, only an admission code can be billed, with no discharge code. For example, at 1 a.m. a patient is admitted to the hospital because of severe gross hematuria (599.7). Emergency cystoscopy (52214) at 7:30 a.m. reveals a small bleeding vessel in the bladder, which is easily fulgurated with spontaneous clearing of urine. The patient is discharged following his supper at 8:30 p.m. Code a hospital admission (99221-99223) with modifier-25 to indicate a significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service and 52214. Do not charge a discharge code, because 52214 has a zero-day global. If the patient goes home the next day, report a hospital discharge (99238-99239) for that day.

Observation Status
 
Hospital observation status is an outpatient place of service and is usually for a stay of less than 24 hours. The emergency department (ED) often serves as the place of service for observation status. After 24 hours of observation, use the established patient office visit outpatient codes (99211-99215).
 
Use observation codes that include admission and discharge (99234-99236) for patients admitted for observation services and discharged the same day. For example, at 7:30 a.m. a patient is admitted to the observation service in the hospital ED with left flank pain (788.0, Renal colic). He remains relatively asymptomatic and is discharged at 8 p.m. Use 99234-99236.
 
If the patient is admitted for observation and discharged the next calendar day, use the initial observation codes (99218-99220) for the first day, and the discharge observation code for the second day (99217). For example, a young female is admitted to the observation service in the hospital ED at 3 p.m. with right pyelonephritis (590.10, Acute pyelonephritis; without lesion of renal medullary necrosis). An excretory urogram (74410, Urography, infusion, drip technique and/or bolus technique) was normal. Intravenous antibiotics improved her clinical status. She is discharged the next morning after breakfast on oral antibiotics. Report the initial observation day with 99218-99220, and report the discharge from observation the next day with 99217.
 
If the patient is admitted to the hospital from observation status, use a combination of observation and inpatient codes. For example, the female in the above example does not improve a lot overnight and is admitted to the hospital the next morning for continued intravenous medication. The next day she is discharged on oral antibiotics. Code day-one observation care (99218-99220); day-two, an initial hospital code (99221-99223); and day-three, a discharge code (99238-99239).

Consultations for Emergencies in Observation
 
When another physician requests a consultation from a urologist for a patient in observation, the urologist uses outpatient consultation codes (99241-99245). Because observation status is by definition outpatient, even though the patient is seen in the hospital, the consultant should use outpatient, not inpatient, codes. 
 
For example, a primary care provider (PCP) calls for a urological consultation for a patient in the observation unit. The urologist uses an outpatient consultation code (99241-99245). The PCP bills the observation code (99218-99220).
  
In another example, a PCP asks a urologist to render an opinion for a 68-year-old male in the observation unit with severe urethral stricture disease (598.xx ) and urinary incontinence (788.3x). The urologist completes the consultation and performs a percutaneous suprapubic cystostomy. The PCP reports an observation code (most likely, 99234); the urologist reports 99243-25 and 51010 (Aspiration of bladder; with insertion of suprapubic catheter). For payment, modifier -25 is appended to an E/M service (consultation, in this case) because it is a significant and separately identifiable service performed on the same day as a minor surgical procedure (zero to 10- day global). Code 51010 has a 10-day global. For CPT and commercial carriers, either modifier -25 or modifier -57 (Decision for surgery) may be appended to the E/M service. For Medicare, modifier -57 is used only when the surgical procedure has a 90-day global period.
 
In another example, because of a urinary tract infection (646.6x, Infections of genitourinary tract in pregnancy) during pregnancy, at 10 p.m. an obstetrician sends a patient to the ED to be seen by the physician. The next morning, the obstetrician admits the patient to observation status and watches her for 48 hours. On the third day he admits her to the hospital for continued care. A urologist is consulted. The ED physician reports the visit (99281-99285, Emergency department visit ...) for the p.m. care. The obstetrician reports 99218 and 99212 for the two days in observation status. The obstetrician codes the third-day admission to the hospital with 99222, and 99232 for subsequent days. The urologist uses 99253 for an in-hospital consultation.

Multiple Visits on Same Day
 
Two visits on the same day by one urologist or a partner for the same or a related problem may be combined into one E/M code at a higher level, based on the work performed at each. Different places of service can lead to separate charges.
 
Use two E/M codes when a patient is seen in the office and in the ED on the same day. For example, a urologist sees a 45-year-old male in the office for acute prostatitis (601.0) and later that evening re-examines him in the ED because of increasing lower urinary tract symptoms. Antibiotics are continued, and the patient is sent home from the ED. Code the new patient visit 9920x at the office (Place of Service #11) and the ED visit 99281-99285 (Place of Service #23). Both visits are payable with the same diagnosis; no modifiers are required.
 
When a patient is seen in the office and the hospital inpatient unit on the same day, bill only one E/M code. For example, the urologist sees a 68-year-old male in the office for acute urinary retention (788.20, Retention of urine, unspecified) and sepsis (599.0, Urinary tract infection, site not specified). He sends the patient to the hospital for admission that night. That evening, the urologist returns to the hospital, re-examines the patient, and writes an admission note and orders. Report only the hospital admission (99221-99223) including the work performed in the office and at the hospital to reach the appropriate level of care.
 
In another example of the above, if the urologist gives orders for admission over the telephone and sees the patient the next morning, bill for the office visit and for the initial hospital visit the next day. Use 9920x for the office visit and, for the next day, bill for the initial hospital admission, probably a low-level code because of the full examination performed in the office the previous day.
 
Note: The admission date for Part A hospital charges does not have to coincide with the urologists initial hospital admission.
 
 In a similar clinical circumstance, the urologist initially examines the patient in the office, then in the ED, and finally admits him to the hospital or observation status, all on the same day. Code only for the initial hospital or observation status admission because the office and ED work are combined in the admission code. If the admission from the ED occurs the next calendar day, bill the office visit and ED visit on one day and the hospital or observation admission the next day. For day one, report 9920x for the office visit and 99281-99285 for the ED; for day two, report 9922x or, if observation, 99218-99220.

Other Articles in this issue of

Urology Coding Alert

View All