Family physicians must occasionally admit patients to the hospital from the office, emergency department (ED) or other sites of service. Coding admissions from these sites can be confusing. Here is what you need to know to do it correctly.
What CPT says
According to CPT, the initial hospital care codes, 99221–99223, are for “the first hospital inpatient encounter with the patient by the admitting physician.” Initial inpatient encounters by other physicians should be reported with either subsequent hospital care codes (99231–99233) or initial inpatient consultation codes (99251–99255), as appropriate.
CPT also offers the following guidance: “When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g., hospital emergency department, observation status in a hospital, physician’s office, nursing facility) all evaluation and management (E/M) 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 [emphasis added]. The inpatient care level of service reported by the admitting physicians should include the services related to the admission he/she provided in the other sites of service as well as in the inpatient setting.”
This same principle applies to the initial observation care codes, 99218–99220. Those codes are used to report “the encounter(s) by the supervising physician [emphasis added] when designated as ‘observation status.’” Observation encounters by other physicians should be coded using the office or other outpatient consultation codes, 99241–99245.
Also note that when a patient is admitted and discharged from either observation status or the hospital on the same date, CPT recommends that codes for same-day admission/discharge, 99234–99236, be used.
What Medicare and other payers say
Medicare requires that a patient be an inpatient or in observation status for a minimum of eight hours to report 99234–99236, but this is not a CPT requirement. Otherwise, Medicare policy and that of other payers generally follows the CPT guidelines with respect to hospital admissions and observation status.
For example, section 15505.1.A of the Medicare Carriers Manual states, in part, “When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.” Also, section 15505.1.F states, “Advise physicians to use the initial hospital care codes (codes 99221–99223) to report the first hospital inpatient encounter with the patient when he or she is the admitting physician.”
What it all means
The following scenarios may help you put the rules into practice:
• You see a patient in the hospital ED. During the course of that encounter, you admit the patient as an inpatient of the hospital. In this case, only an initial hospital care code, 99221–99223, should be submitted. Since the ED visit was related to the admission and occurred on the same date, you cannot separately code for that visit.
• You see a patient in your office. During the course of that encounter, you admit the patient to the hospital as an inpatient, but do not see the patient in the hospital that day. The next day, you visit the patient in the hospital for the first time. In this case, you would code an office visit (99201–99215) for services provided on the first day and an initial hospital care code (99221–99223) for services provided on the second day. Because you did not see the patient in the hospital the first day, you could not code 99221–99223 for that service since, as noted, these codes are for “the first hospital inpatient encounter with the patient by the admitting physician.” In this scenario, that encounter took place on the second day and is coded accordingly.
• You treat a patient in your office for an ear infection. That evening, you encounter the patient in the ED where she’s having severe asthma and admit her as an inpatient of the hospital. In this case, you could use an office visit code for the morning encounter and an initial hospital care code for the admission that evening. You would probably need to attach a -25 modifier (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the office visit code to indicate that it was unrelated to the subsequent admission. In this case, submitting different diagnosis codes would help further establish the appropriateness of coding both services.
• You see a patient in the ED. During the course of that encounter, you admit the patient to observation status at the hospital. Later that day, you determine that it is appropriate to discharge the patient to her home. In this case, you would use one of the codes for observation or inpatient care involving admission and discharge on the same date of service (i.e., 99234–99236); you would not separately code the ED visit.
It’s worth your time
Coding for hospital admissions from other sites of service can be confusing. However, since payers and CPT are generally playing by the same rules in this case, once you master the rules, appropriate reimbursement should follow.