Ophthalmology and Optometry Coding Alert

Question: My ophthalmologist treated a 2-year-old patient who was in an automobile accident and had multiple facial and eyelid lacerations. He admitted the patient at 8 p.m. and performed the repair. Then, the physician discharged the patient at 2 a.m. Is it appropriate to report the admission on the first day with modifier 25 or 57 and the layered-closure code (12052), and then report the discharge for the second date of service when the patient was only in the hospital for six hours?

Tennessee Subscriber Answer: Before you can code this encounter, it is important that you determine the "status" of the patient's admission to the hospital. Was it an observation admission status or inpatient admission status?

If the patient status was observation admission, code the appropriate level of codes 99218-99220 (Initial observation care, per day) for the first date of service and 99217 (Observation care discharge) for the second date. But if the status was inpatient admission, report the appropriate level of codes 99221-99223 (Initial hospital care, per day) for the first date and 99238 (Hospital discharge day management; 30 minutes or less) or 99239 (... more than 30 minutes).

Bottom line: If the physician saw the patient both days, you can report both the admission and the discharge although the patient was in the hospital for only a few hours. There must be an admission note on the medical record meeting the level of history, exam and medical decision-making and a separate discharge summary to bill both codes.

Caution: You might think you should report a same- day observation admission and discharge from the 99234-99236 series (Observation or inpatient hospital care, for the E/M of a patient including admission and discharge on the same date). But you can only use these codes for services the ophthalmologist performs on the same calendar day of at least eight hours or more, not just within a 24-hour period. So if the patient had been admitted at 8 a.m. and discharged at 2 p.m., you could have used the appropriate 99218-99220 for observation and discharge on the same date, less than eight hours.

If the observation admission and discharge on the same calendar date is eight hours or more, assign the appropriate level from the 99234-99236 series.

Report the patient's admission using the appropriate admission code (99221-99223) appended with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service), and also report the layered-closure code (12052, Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 to 5.0 cm) with no modifier for the surgical repair on the first date. Then, with the second date, report the appropriate discharge [...]