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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.

Medical coding books

Medical coding books

11 Responses to “Office E/M + Inpatient Admission = One Code”

  1. Diane Bradford says:

    But then how do you bill the progress notes for subsequent hosp visits if you don’t have an initial inpatient visit?

  2. Sarah Cruz says:

    You left out a critical requirement – in order to bill Initial hospital care, the physician must see the patient in the hospital on the same DOS. Often the physician has a day full of office patients and doesn’t get over to the hospital. In that case, you have to bill the office visit.

  3. Sarah Cruz says:

    From WPS (check your carrier for specific rules):
    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.

  4. Chastity Nault says:

    It would also depend on if the physician was the admitting physician or if Hospital Medicine admitted the patient.

  5. Nina says:

    We changed to a new Medicare vendor not long ago; but Trailblazers and Novitas agree on this. If the service was not rendered IN the inpatient hospital place of service, the Initial Hospital Care Codes cannot be used. Therefore, the physician that sees the patient in the office and sends the patient directly to the hospital will need to make time to visit, evaluate and document said visit in the hospital. Alternatively, he or she can charge an office visit and then transfer the care to a hospitalist who has time to render the services when needed.

  6. Ben Thomas says:

    I they are established patient admitted underobservtion then they would still be 99215 aas observation is considered “not inpatient” corrent?

  7. Ben Thomas says:

    Sorry for ? sp….If they are an established patient admitted unde robservtion then they would still be 99215 aa\s observation is considered “not inpatient” corrent?

  8. Cheryl says:

    How does this work if 1 doctor sees the pt in the office and admits him but the on call doctor says use the office E/M as the hospital H&P and Dr 1 doesn’t ever see the pt while in the hosp.

  9. savannah says:

    What if your provider is not connected to the hospital the pt came in our clinic got some lab work done and our physician seen them and they wanted them to go to the ER how can we bill our services in office?

  10. Pshis says:

    I need some clarification on this please. Our Physician saw the patient in the office and then recommended the patient go to the ED. Our office billed 99213.
    The ED Physician then admitted the patient. Our office and the Hospital in question are all under the same Hospital system. We are now getting a denial as our 99213 is hitting up against the Hospital 99223. The patient has Medicare. What would be done in this scenario?
    Thank you

  11. Lee Fifield says:

    Medicare will not bill for two E/Ms for the same patient on the same day unless they are for separate and significant services. In this situation, the service is for the same problem even though the patient is being seen by two different physicians. So, I believe the inpatient admission code (the 99223) would be the only one billed, unless the outpatient physician sees the patient in the hospital after admission but on the same day. Then, the outpatient physician would claim the inpatient admission code, probably at a higher level because they have done the initial workup before admission.