Wiki Transfer of Care

[mnorth2007]

A patient comes into the hospital and is admitted to the trauma service. After the first initial couple days, they are then transfered to IM and IM follows them until they are discharged. There is no consultation order, but there is a transfer order. IM doctor writes a note titled progress note but has all the elements of a H&P. Are we able to code this first visit with the IM physician as a 99221 or 99222, or does it need to be coded as a subsequent day 99232 or 99233?

 

[thomas7331]

A patient comes into the hospital and is admitted to the trauma service. After the first initial couple days, they are then transfered to IM and IM follows them until they are discharged. There is no consultation order, but there is a transfer order. IM doctor writes a note titled progress note but has all the elements of a H&P. Are we able to code this first visit with the IM physician as a 99221 or 99222, or does it need to be coded as a subsequent day 99232 or 99233?

If an IM specialist has not yet seen the patient during the current admission, then yes, you can code this as an initial visit with 99221-99223 as long as the documentation meets the requirements for that code.