Part B Insider (Multispecialty) Coding Alert

Published on Mon Jan 25, 2010 PDF

Codes 99221-99223 refer to inpatient care.

Myth: If your physician admits a patient to the hospital, you are justified in reporting an "admit code."

Reality: CPT does not include a code for hospital admission itself.

The admitting physician should report codes 99221-99223 for his care if he documents the elements contained within the codes (appropriate history, exam and medical decision-making). He is not billing for the admit itself - he's billing for the care that he provides, based on the documentation.

"CPT clearly states that the initial hospital care codes should be used to report the 'first hospital inpatient encounter with the patient by the admitting physician,'" says Joan Gilhooly, CPC, PCS, CHCC, president of Medical Business Resources, LLC in Deer Park, Ill.

Because codes 99221-99223 refer to the physician's "inpatient encounter," it's clear that the patient has already been admitted -- otherwise he or she would not be classified as an inpatient.

"Physicians get paid for the care they provide, not for administrative work," Gilhooly says. Processing the admission, including dictating the required H&P, counts as administrative work, not medical care.

Why this matters: Suppose a physician sees a patient in his office on Monday, and decides that the patient requires a hospital admission. He sends the patient to the hospital but does not perform initial hospital care until Tuesday. Can the practice bill initial hospital care on Monday (for the "admit") and subsequent hospital care on Tuesday?

Answer: No. The practice should report an office visit on Monday and an initial hospital care code on Tuesday, Gilhooly says.

Note: "Under the hospital's conditions of participation with Medicare, it's a requirement that there be a history and physical (H&P) on the record within 24 hours after admission,"

Gilhooly says. "The H&P can be conducted up to 30 days prior to admission, but must be on the chart within 24 hours."

"The fact that the H&P can be done up to 30 days ahead of time tells you that it has nothing to do with billing," Gilhooly says. "It makes sense to do that H&P during the first visit with an inpatient, but if you choose to do the work or dictate the work associated with the H&P earlier, that's not an inpatient service."