Cardiology Coding Alert

Inpatient and observation admissions can be difficult to code even under the best of circumstances, but coding becomes even more complicated if the hospital admits the patient on one calendar day and the treating physician's initial encounter with the patient falls on the following calendar day.
 
This can occur, says Marko Yakovlevitch, MD, FACP, FACC, a cardiologist in private practice in Seattle, "When a patient arrives in the emergency department (ED) who is stable but still potentially at risk for an adverse coronary event and cannot be sent home directly from the ED. The patient is admitted to the care of the on-call cardiologist, who only sees the patient the next morning."
 
There are several issues to consider when coding these services, starting with a precise definition of "admission," says Gay Boughton-Barnes, CPC, MPC, CCS-P, chief medical compliance officer at the University of Oklahoma Medical Center in Tulsa. "I get a lot of questions about this issue," she says. "The word 'admission' is confusing in itself. It can mean different things to physicians, hospitals and carriers."
 
The physician's report on the date and nature of the admission may conflict with the hospital's report: 
  The hospital may indicate that the patient was admitted the night before, whereas the attending cardiologist may (correctly) consider the patient admitted on the following day and bill for the initial encounter on that basis.
  The place of service listed by the hospital and the physician may differ.
  The physician may admit the patient to inpatient status, but the hospital lists the patient as observation.
The CPT manual includes three observation care codes (99218-99220) and three inpatient care codes (99221-99223). Although all six codes are clearly linked to admissions, the code descriptors refer to "initial care" and not admissions per se. In other words, Boughton-Barnes says, for the cardiologist, the date listed for the hospital admission is not the key factor in determining when the admission should be reported; rather, the date that the initial care (which requires face-to-face contact) was provided is the deciding factor.
 
Yakovlevitch offers an example:
 
A 65-year-old woman who had a left anterior descending stent placed three months earlier and was pain-free until a week ago starts to notice chest pain with diminishing degrees of exertion. She develops pains on Friday merely walking from her bed to the bathroom. Her husband brings her to the ED, where she is diagnosed with crescendo angina and admitted to the care of the on-call cardiologist. The patient is placed on intravenous heparin and topical nitrate therapy, aspirin, metoprolol and intravenous fluids for probable cardiac catheterization.
 
In this situation, the cardiologist reports the appropriate level of inpatient care code (99221-99223) for his or her first visit (Saturday morning). The discharge [...]