Pediatric Coding Alert

Question: Our office recently had a patient for whom we performed a complete history and examination, including lab work. We decided to admit the patient, who subsequently arrived at the hospital and was evaluated by the specialist but never admitted. Our office billed 99222 for the admission because we did all the paperwork and contacted everyone required. Was this correct?

Louisiana Subscriber

Answer: In this situation you may not bill an admission because the patient was, in fact, not admitted. You should use an office visit code, possibly a 99214 or 99215 for an established patient or 99204 or 99205 for a new patient. The documentation in the chart should clearly describe the work undertaken as well as the level of examination and complexity of the visit.