Gastroenterology Coding Alert

Question: Our gastroenterologist saw a patient in the hospital for a surgical evaluation but chose to admit the patient for acute gastroenteritis and dehydration requiring IV hydration. The next day, the patient was stable but refusing oral intake. The gastroenterologist conducted a brief interval history of present illness and a limited exam of the GI system. He revised a minimal amount of data and ordered more IV fluids without additives. Do we report initial hospital care or subsequent hospital care?

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Answer: The provider who admits the patient to the hospital should report an initial hospital care code for that date (99221-99223, Initial hospital care, per day…). If your surgeon is the admitting physician, you should not additionally report a code from the range 99231-99233 on the admission date. Instead, the admitting physician must combine multiple visit notes for the day into a final, single E/M hospital admission code. For each subsequent day that your surgeon provides E/M services, you can bill the appropriate subsequent hospital care code – so in your situation, you’ll report an initial hospital care code for the first day and a subsequent hospital care code for the second day.

Exception: If your surgeon is not the admitting physician, but provides an E/M service for a Medicare patient on the admission date, you can report a subsequent hospital care code. That’s because Medicare does not accept the consultation codes, which you would ordinarily use to report your surgeon’s consultation with a hospital inpatient under another physician’s primary care.