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Gastroenterology Coding Alert

Reader Question: Initial Hospital Care Services

- Published on Sun, Apr 01, 2001
Question: The three doctors in our practice rotate coverage. Doctor #1s patient comes into the emergency room, but doctor #2 is contacted because hes on call. Because this patient is well known to all the doctors in our practice, doctor #2 talks with the emergency room physician and admits the patient to the hospital via phone. The next day, doctor #1 finishes the paperwork related to the admission and then performs an endoscopic retrograde cholangiopancreatography (ERCP). Who should bill for the hospital admission, doctor #1 or #2?

Oregon Subscriber

Answer: Neither gastroenterologist can bill for the hospital admission because neither one performed a billable evaluation and management (E/M) service, says Pat Stout, CMC, CPC, an independent gastroenterology coding consultant and president of OneSource, a medical billing company in Knoxville, Tenn.

This situation with the gastroenterologist admitting the patient to the hospital occurs frequently, she says. To bill for a hospital admission, however, you have to do more than fill out some papers. Technically, you are not billing a hospital admission. Codes 99211-99223 are for initial hospital care and require the three key components of an evaluation and management service (history, examination and medical decision-making). They also require that the gastroenterologist have face-to-face contact with the patient, which automatically rules out doctor #2 because he only spoke with the emergency room physician and never examined the patient.

If doctor #1 examines the patient before performing the ERCP, he may bill for the initial hospital care service, Stout says. Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be attached to the E/M code to indicate that it is a significant, separately identifiable service. The level of service billed will depend on the level of history, examination and medical decision-making that doctor #1 performed during his evaluation.

AMA coding guidelines allow this service to be billed even when it occurs on the day after the patient is admitted to the hospital. According to Principles of CPT Coding, published by the AMA, the guidelines for this series of codes indicate that they are intended to be reported for the first hospital inpatient encounter with the patient by the admitting physician. This date may not be the same as the date the patient was actually admitted to the hospital.

However, your question did not state that doctor #1 examined the patient before the ERCP was performed, and it is quite possible the gastroenterologist proceeded directly to the operating room with the patient because he was already familiar with the patients symptoms and diagnosis. If there was no face-to-face evaluation of the patient, then no initial hospital care [...]

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