Hospital admissions: Coding scenarios to consider

Q: How do you bill situations when you see the patient in the office and then direct the patient to go to the emergency department (ED)?

A:Coding for hospital admissions from other sites of service can be confusing. However, once you master the rules, appropriate reimbursement should follow.

In this type of situation, we aren’t adding services together because two different physicians are involved. So if a physician sees the patient in an office, works the patient up and then sends the patient to the ED to be evaluated or admitted by another physician, you can bill your office visit separately from any of the hospital charges.  

Since the physician in the office is most likely of a different specialty than the ED physician, both services can be billed. The payer will decide to pay the claim based on how your physicians are credentialed with that payer.

Scenario 1

Physician sees patient in the office, and decides to admit the patient to the hospital as an inpatient. The physician then goes to the hospital to see the patient the same day.

In this scenario, the services performed in the office and at the hospital are rolled together and only the initial inpatient care code is billed (99221-99223). You would not bill the office visit; however, those services can count toward your level of initial inpatient care code, which could increase your code level. Your physician should document separately an office note and an initial hospital note.

Scenario 2

The physician sees a patient in the office. During the course of that encounter, the physician admits the patient to the hospital as an inpatient, but does not see the patient in the hospital that day. The next day, he/she visits the patient in the hospital for the first time.

In this case, you would code an office visit (99201–99215) for services provided on the first day and an initial hospital care code (99221–99223) for services provided on the second day. Because the physician didn’t see the patient in the hospital the first day, you could not code 99221–99223 for that service since, as noted, these codes are for “the first hospital inpatient encounter with the patient by the admitting physician.” In this scenario, that encounter took place on the second day and is coded accordingly.

Scenario 3

The physician sees a patient in your office, and the patient has respiratory distress upon arrival. The physician calls for an ambulance to take the patient to the hospital where the patient is admitted by a different provider.

In this scenario, you wouldn’t bill an office visit because no evaluation and management service was performed.

Scenario 4

Your physician sees a patient in the office, and the patient’s blood pressure is very high, so the physician administers medication  to help bring it down. The patient’s blood pressure is monitored in the office but, after some time, the patient is sent to the ED because she develops a severe headache and chest pain. The physician does not see patients in the hospital.

In this scenario, since the physician worked up the patient, an office visit (99201-99215) should be billed.