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Orthopedic Coding Alert

Want to Collect for ED Work and Inpatient Admit? Here's How

Published on Fri May 14, 2004

You may be able to increase your E/M coding level 
 
Your orthopedic surgeon sees a patient in the emergency department (ED) and subsequently admits him as an inpatient. He can't report two E/M codes on the same date, so he has to forfeit reimbursement for the ED visit, right? Wrong.

You may be able to collect reimbursement for both services by using the physician's ED documentation to increase the inpatient E/M code level. 

Report Only 1 E/M Code

Orthopedists often see patients in the ED and, after examination, admit them to the hospital. The pre-admission examination can be extensive, lasting 30 minutes or more in some cases. But under most payers' guidelines (and as explicitly stated in the Medicare Carriers Manual, section 15047[G]), the surgeon can report only an initial hospital care code (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...) if the ED visit and subsequent hospital admission occur on the same day.

Look out: "You can't bill for two E/M codes on the same day. Most carriers will only pay for one service, and physicians normally choose the code that has the higher reimbursement, which is usually the inpatient E/M code," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center.

Medicare and CPT Agree: Bill Only 1 E/M

Problem: Medicare isn't the only source that limits your claim to one E/M code -- CPT guidelines echo Medicare's policy. "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (that is, hospital emergency department, observation status in a hospital, physician's office, nursing facility), all services that the physician provides in conjunction with that admission are part of the initial hospital care when performed on the same date as the admission," CPT states.

Solution: You can consider the physician's ED work when you select the initial hospital care code (99221-99223), says Suzan Hvizdash, BSJ, CPC, physician education specialist at the University of Pittsburgh's department of surgery.

"The inpatient-care level of service reported by the admitting physician should include the services related to the admission he or she provided in the other sites of services as well as in the inpatient setting," CPT states.

In other words, you can consider the physician's ED examination, history and medical decision-making (MDM) to select the appropriate initial hospital care code. 

If You Document It, Use It

When you review the initial hospital care codes, examine your physician's ED and inpatient documentation, and don't skip the MDM section. Medical decision-making is generally the deciding factor when choosing an initial care code because even the lowest-level service requires a "detailed or comprehensive" history and examination, Jandroep says.

The physician must consider three factors when he selects the MDM level:

  • Mortality and morbidity. What are the risks of significant complications, death or comorbidities associated with the patient's presenting problems, diagnostic procedures, and/or possible management options?

  • Diagnosis and management options considered. Has the physician established a definitive diagnosis? Has the physician written a plan of care, or is he awaiting further information? Will he order further assessment, tests, medical studies or consultations?

  • Records and tests reviewed. How many tests and medical records did the orthopedist review and analyze, and how complex were they? Did the physician review the films or tracings himself? (Orthopedic surgeons often do this but rarely document it, even though it can substantially increase the MDM level in some situations.)

    Presenting Problems Are Key

    The patient's presenting problems in the ED can affect MDM, and this can carry over to the inpatient E/M level of service.

    Example: An auto-collision patient presents to the ED with a bruised neck. The patient initially claims to feel fine and protests that he only visited the ED because his wife insisted. During the history and physical, the patient's neck pain worsens. Concerned about the possibility of a cervical spinal fracture (805.x), the orthopedist orders testing and identifies a fracture requiring surgical repair. He admits the patient to the hospital immediately.

    In this case, the possibility of serious injury required a high-level history and exam. During the exam, as the patient's symptoms became more apparent, the MDM level also increased because the risk to the patient, as well as the tests the orthopedist reviewed and the diagnoses/management options he considered, increased as well.

    Hint: When an orthopedist determines that the patient requires admission, his work describing the ED visit carries over to the initial inpatient care codes, and he needn't record a "new" history and physical. 

    In the above example, the complexity of MDM, combined with the comprehensive history and exam,  would probably allow you to report a level-two inpatient admission (99222) with little additional work beyond that included in the ED visit alone.

    If Surgery Follows Admission, Append -57
     
    If your orthopedist admits a patient to the hospital and immediately performs surgery, you should append modifier -57 (Decision for surgery) to the initial inpatient E/M code to differentiate it from the usual preoperative exam that insurers include in the global surgical package.

    In the above example, for instance, append modifier -57 to 99223 and separately report the fracture repair (22326, Open treatment and/or reduction of vertebral fracture[s] and/or dislocation[s], posterior approach, one fractured vertebra or dislocated segment; cervical).

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