ELBrock
Networker
- Messages
- 59
- Location
- Marana, AZ
I have a record I am trying to code where a pregnant patient, 29 weeks, presented to Labor and Delivery with complaint of painful contractions.
The nurses notated that the provider was paged, and later returned the call and ordered the patient to be admitted and Magnesium Sulfate to be given. This was around 2 am.
Later, at around 9 am, the provider documents a progress note. It is very brief:
"Pt admitted for painful ctx and cx 1cm. Pt did not respond to tocolytics.
Pt now on MGSo4 and receiving steroids.
Pt did have intercourse within 24 hours.
Ctx spacing.
ffn 25 hrs post last cervix exam and sono for position and wt."
Since there is no H&P or exam or really any admission records...I would not bill for an initial hospital care code, right? The provider visited the patient 3 times this day with other progress notes similar to this one and then discharged the next day with a full discharge summary. Would it be appropriate to bill a subsequent hospital care code for this admission day? I know CMS did give direction that if the E/M code could not be leveled as detailed/comprehensive, that we could use subsequent hospital care codes, but I'm worried that is only valid for services that could be considered "consultation" codes.
"Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241-99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay."
I seem to get a lot of these "Phone" admits in labor and delivery, and there is no H&P done do level an E/M; Just a progress notes.
Any help would be appreciated! Thank you!
The nurses notated that the provider was paged, and later returned the call and ordered the patient to be admitted and Magnesium Sulfate to be given. This was around 2 am.
Later, at around 9 am, the provider documents a progress note. It is very brief:
"Pt admitted for painful ctx and cx 1cm. Pt did not respond to tocolytics.
Pt now on MGSo4 and receiving steroids.
Pt did have intercourse within 24 hours.
Ctx spacing.
ffn 25 hrs post last cervix exam and sono for position and wt."
Since there is no H&P or exam or really any admission records...I would not bill for an initial hospital care code, right? The provider visited the patient 3 times this day with other progress notes similar to this one and then discharged the next day with a full discharge summary. Would it be appropriate to bill a subsequent hospital care code for this admission day? I know CMS did give direction that if the E/M code could not be leveled as detailed/comprehensive, that we could use subsequent hospital care codes, but I'm worried that is only valid for services that could be considered "consultation" codes.
"Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241-99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay."
I seem to get a lot of these "Phone" admits in labor and delivery, and there is no H&P done do level an E/M; Just a progress notes.
Any help would be appreciated! Thank you!