Wiki How would you code scenario?

[Partha]

Patient was seen in office and was hydrated –cpt 99215 and 96360 and 96361 then patient was admitted to hospital same day and Dr went to admit her with another evaluation.

 

[FTessaBartels]

One E/M - Hospital admit

You only code one E/M on one date of service, and CPT tells us specifically that you should code the Initial Hospital Visit (9922x). Use all the documentation, including the office visit, to determine your level of service.

F Tessa Bartels, CPC, CEMC

 

[Partha]

Thanks

Thanks for confirming - suddenly the provider comes up with a question...which you have always known, raises a doubt in your mind, you feel it's necessary to take a second opinion.

 

[SuzanBerman]

Exactly right-the initial inpatient service should be the one coded. However, I would ask the question, did the MD see the patient upon admission in the hospital?

Only 1 E/M service can be billed, however, if he didn't see the patient in the hospital then the intial service code would not be billable.

I totally understand when you start to doubt yourself. I do that a few times a day sometimes.

Suzan Berman CPC, CEMC, CEDC