Initial Hospital Service Matters More than Admission Date
Consider this hypothetical scenario: Your physician admits a patient to the hospital just before midnight on Friday, but doesn’t see the patient until early the following morning. Which is the proper date of service?
Although 99221-99223 often are called “admission codes,” what they actually describe is the initial evaluation and management (E/M) of the patient in the hospital. Per CPT® guidelines, you should use 99221-99223 “to report the first hospital inpatient encounter with the patient by the admitting physician” [emphasis added].
In other words, the proper date of service is when the billing physician actually sees the patient in the hospital for the first time. The date the hospital admission occurs is irrelevant.
Several Medicare contractors explicitly support this policy. For example, WPS Health Insurance offers the following Q&A examples on its webpage:
Question 1: When the physician provides a direct admit from the office, can we bill an initial hospital visit even though the physician does not go to the hospital on that day?
Answer: No. An initial hospital visit code is the first encounter with the patient as an inpatient in the hospital. Billing an initial hospital visit procedure code is not appropriate if the physician does not see the patient in the hospital. The physician would bill the office visit and then bill the initial visit code when he/she sees the patient in the hospital. If the physician sees the patient in the hospital on the same day as a visit in another site of service, only the initial hospital visit may be billed.
Question 8: The patient was admitted to the hospital on the 10th, but I did not see the patient until the 11th. Should I bill the initial visit on the 10th or 11th?
Answer: You would not be able to submit charges for the 10th as you did not see the patient on that day. The admitting physician bills the initial hospital visit the first time he/she sees the patient in the hospital. You can only bill the initial visit on the day it was performed —the 11th.
Question 10: I saw the patient in my office, completed an H&P, and sent them to the hospital for admission. Can I bill an initial hospital visit?
Answer: No. The physician may bill an initial hospital visit only when he/she sees the patient for the first time in the inpatient setting.
Note, as well, that any visits after the initial E/M for the same patient during the same hospital stay will be considered subsequent hospital care, as also explained by WPS policy.
Question 9: I admitted the patient on the 10th and saw them briefly. I performed the H&P on the 11th. Can I bill a subsequent code on the 10th and the hospital admission on the 11th?
Answer: The initial hospital visit procedure codes are used the first time the admitting physician sees the patient in the hospital. In the example, the initial visit is on the 10th, however it is important to choose the procedure code based on the documentation. If your documentation does not support the use of the lowest initial inpatient procedure code, 99221, then submit a subsequent procedure code. The service on the 11th is a subsequent hospital visit.