Office E/M + Inpatient Admission = One Code
Occasionally, a physician may see a patient in the office and send that patient immediately to the hospital for admission. In such a case, you may consider the history and physical (H&P) taken in the office when determining the inpatient admission level (e.g., 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity.). Although the H&P do not have to be dictated at the hospital, if any additional workup is performed at the hospital, you may consider that work—in addition to the H&P performed in the office—when assigning a service level.
What you should not do is report an office visit (e.g., 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity.) in addition to the inpatient admission. Instead, choose a single code (the admission) that best describes all of the evaluation and management (E/M) work provided to the patient on that day.
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