Part B Insider (Multispecialty) Coding Alert

Published on Mon Jan 25, 2010 PDF

Collect every penny of your hospital care services.

Now that Medicare has stopped paying you for consult codes, it's more important than ever to report the office visit and hospital care codes accurately. Get to know two important truths about hospital care and you'll be on your way to coding success.

Fact 1: Combine Outpatient E/M With Initial Hospital Care Record for Same-Day Admits. If you see a patient in your office and subsequently perform initial inpatient care for the same patient on the same date, you should report just one E/M code.

"According to CPT coding rules, when both services are provided in the same calendar date, the work performed and documented in the office is combined with the work performed and documented in the hospital to determine the appropriate level of initial inpatient care (99221-99223)," states Joan Gilhooly, CPC, PCS, CHCC, president of Medical Business Resources, LLC in Deer Park, Ill.

"Let's say you performed four elements of the history of present illness, five elements of review of systems, you've asked about past, family and social history, and you performed a detailed exam in the office setting -- and the decisionmaking results in wanting to send the patient to the hospital," Gilhooly says. "When the physician sees the patient in the hospital, he's not going to do all of those history elements again, so those become part of the documentation in the initial hospital care code that the doctor will report." Initial hospital care codes 99221-99223 include all E/M services connected to a hospital admission when provided on the same date of service.

The rules: The Medicare Claims Processing Manual (Chapter 12, Section 30.6.9.1) states, "When the patient is admitted to the hospital via another site of service (e.g.,hospital emergency department, physician's office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission." CPT guidelines for "Initial Hospital Care" similarly instruct that "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g., hospital emergency department, observation status in a hospital, physician's office, nursing facility), all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission."

Fact 2: Use Modifier 57 if the Initial Inpatient Visit Results in a Surgery. If surgery immediately follows an admission to the hospital, you should append modifier 57 (Decision for surgery) to the initial inpatient E/M code to differentiate it from the usual preoperative exam included in the global package, says Jay Neal, an Atlanta-based coding consultant.

Suppose a patient presents to the emergency room with abdominal pain after falling off a railing. During the history and physical, the patient begins to have abdominal pain, dizziness and nausea.

Concerned about the possibility of internal injury, the physician admits the patient and, upon diagnostic testing, identifies a liver laceration requiring surgical repair.

If surgery is performed the day of or the day after this type of admission to the hospital, you should append modifier 57 to the appropriate E/M code, Gilhooly says. Then, separately report the liver repair (47360, Management of liver hemorrhage ...) as well.