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Two E&M visits in Hospital in one day?

  1. Default Two E&M visits in Hospital in one day?
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    I think I know the answer already but I am going to ask just to be sure. My doctor sees patient in hospital and admits him at 1:05am, he then visits him in the afternoon. Can I bill out both visits? Thanks, Gail Davis, CPC.

  2. #2
    I'm going to say no because the your doctor is seeing the patient again for the same reason/condition that admitted the patient. The work from the second visit needs to be added to the work he did for the admission and bill that as one E/M.

    This is my take according to what I've seen and read from previous postings! Please correct me if I'm wrong!

  3. Default E/M
    Per the CPT Manual (Hospital Inpatient Services) When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (eg. hospital emergency department, observation status in a hospital, physician's office, nursing facility) all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. The inpatient care level of service reported by the admitting physician should include the services related to the admission he/she provided in the other sites of service as well as in the inpatinet setting.

    My take on this is that you cannot code them separately. Both incidents have to be coded with one code, I would think that you would add the times spent with the patient, together to choose the correct code, and compare to the level of history, exam and MDM to choose the correct code for all visits of the patient throughout the day.

  4. Default
    I agree and felt that was the rule of thumb per the guidelines but with it being an admit at midnight and a visit at the end of the day, just wasn't sure. Thank you!

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