Wiki Admit from the Office to Inpt. Hospital

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jackjones62

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Am I crazy? I am working towards my Audit Cert. and was dinged for an incorrect answer which I swore I was correct. A Pedi admits a patient from the office to the hospital, I responded that the office E/M work would be incorporated into the Admission, that only the initial Hospital Visit could be charge for that date of service. WRONG! CPT Guidelines support the Initial Hospital Visit and the E/M service: Rationale: According to CPT® guidelines: “When the patient is admitted to the hospital as an inpatient or to observation status in the course of an encounter in another site of service (eg, hospital emergency department, office, nursing facility), the services in the initial site may be separately reported. Modifier 25 may be added to the other evaluation and management service to indicate a significant, separately identifiable service by the same physician or other qualified health care professional was performed on the same date.” The provider admitted the infant to the hospital from his office and continued the care on the same date of service. The provider documented a new problem with uncertain prognosis and admission to the hospital to support a moderate complexity MDM in the office on an established patient, 99214 with modifier 25. In the hospital, the provider ordered three unique test and prescription drug management for a moderate complexity. The appropriate code is 99222.

Did the guideline change somewhere along the way??? Was I not paying attention. I can't imagine any carrier paying 2 related E/M services on the same day by the same providers.

Thank you in advance for your input, lol, still shaking my head!

Jennifer, CPC, CRC and hopefully CPMA!
 
jackjones62 said:
Am I crazy? I am working towards my Audit Cert. and was dinged for an incorrect answer which I swore I was correct. A Pedi admits a patient from the office to the hospital, I responded that the office E/M work would be incorporated into the Admission, that only the initial Hospital Visit could be charge for that date of service. WRONG! CPT Guidelines support the Initial Hospital Visit and the E/M service: Rationale: According to CPT® guidelines: “When the patient is admitted to the hospital as an inpatient or to observation status in the course of an encounter in another site of service (eg, hospital emergency department, office, nursing facility), the services in the initial site may be separately reported. Modifier 25 may be added to the other evaluation and management service to indicate a significant, separately identifiable service by the same physician or other qualified health care professional was performed on the same date.” The provider admitted the infant to the hospital from his office and continued the care on the same date of service. The provider documented a new problem with uncertain prognosis and admission to the hospital to support a moderate complexity MDM in the office on an established patient, 99214 with modifier 25. In the hospital, the provider ordered three unique test and prescription drug management for a moderate complexity. The appropriate code is 99222.

Did the guideline change somewhere along the way??? Was I not paying attention. I can't imagine any carrier paying 2 related E/M services on the same day by the same providers.

Thank you in advance for your input, lol, still shaking my head!

Jennifer, CPC, CRC and hopefully CPMA!
Click to expand...

It was part of the 2023 E/M updates. See page 23 of this PDF from the AMA website: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

In the 2025 CPT book, you can find the same paragraph on page 21 under Initial Hospital Inpatient or Observation Care - New or Established Patient
 
To me, the use of modifier 25 would likely not be supported if the two E/Ms were related. Despite this guideline change, I have not seen any instances like this pay.
 
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