The patient is in her second trimester and is seen in the ER for flank pain. The ER Doctor calls our on-call OB doctor, who agrees to admit the patient to the women's center.
So our Doctor is the admitting doctor, but this is all done via phone.
The patient is transferred to the women's center and admitted as an inpatient and attended to by the nurses. The nurses are following all orders from the physician via phone, and notes verify the doctor is being updated on all changes.
The doctor comes in the next day to see patient and discharges her home.
I'm wanting to code this with 99221, 99238.
It appears the history/exam were not all re-done, since the records came over from the ER with a diagnosis of kidney infection in second trimester.
Can those ER records be used to level the initial hospital care code (99221,99222, or 99223), since that information was used to admit the patient? Or since that was a different location and different doctor, can we not?
Or am I off the mark, and we wouldn't even be using initial hospital care codes in this situation? Our doctor is a hospitalist for the Women's Center.
Thank you very much!
So our Doctor is the admitting doctor, but this is all done via phone.
The patient is transferred to the women's center and admitted as an inpatient and attended to by the nurses. The nurses are following all orders from the physician via phone, and notes verify the doctor is being updated on all changes.
The doctor comes in the next day to see patient and discharges her home.
I'm wanting to code this with 99221, 99238.
It appears the history/exam were not all re-done, since the records came over from the ER with a diagnosis of kidney infection in second trimester.
Can those ER records be used to level the initial hospital care code (99221,99222, or 99223), since that information was used to admit the patient? Or since that was a different location and different doctor, can we not?
Or am I off the mark, and we wouldn't even be using initial hospital care codes in this situation? Our doctor is a hospitalist for the Women's Center.
Thank you very much!