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Understand the "fine print" when selecting the correct codes for patient admissions from clinic to hospital
1University of Oklahoma Health Science Center, USA.
Insights
Physicians billing for clinic visits followed by hospital admissions must consider face-to-face contact. If no hospital encounter occurs the same day, bill clinic and hospital services separately.
Area of Science:
- Medical Coding and Billing
- Healthcare Administration
Background:
- Physicians often encounter situations where a patient is seen in a clinic and then directly admitted to the hospital on the same day.
- Accurate coding and billing for these services require a nuanced understanding of Current Procedural Terminology (CPT) guidelines, particularly regarding evaluation and management (E/M) services.
Purpose of the Study:
- To clarify the appropriate coding and billing procedures for physicians when a patient encounter transitions from a clinic visit to a hospital admission on the same date.
- To address the interpretation of "encounter" in CPT guidelines and its impact on billing for initial hospital care versus separate clinic services.
Main Methods:
- Analysis of CPT code descriptions and guidelines, specifically focusing on "Initial Hospital Care" codes (99221-99223) and E/M services.
- Examination of the definition of "encounter" within the context of physician-patient interactions in different care settings.
- Distinguishing between same-day clinic and hospital encounters versus separate-day encounters.
Main Results:
- The CPT guidelines state that E/M services provided by a physician in another site of service (e.g., clinic) on the same date as a hospital admission are considered part of the initial hospital care.
- However, the CPT definition of "encounter" for initial hospital care implies a face-to-face interaction with the patient in the hospital setting.
- If a physician does not have a face-to-face encounter with the patient in the hospital on the same date as the clinic visit, it is inappropriate to bill using the "Initial Hospital Care" codes.
Conclusions:
- When a patient is seen in the clinic and admitted to the hospital on the same day, but the physician does not have a face-to-face hospital encounter that day, the clinic visit should be billed separately using "new" or "established" patient office visit codes.
- The initial hospital service should be billed on a subsequent date when the physician actually has a face-to-face encounter with the patient in the hospital.
- This approach ensures accurate billing and reflects the distinct services provided in each care setting.
Abstract:
How should a physician code and bill for services when a patient is seen in the clinic and then is directly admitted to the hospital? The correct answer is not as straightforward as it might at first seem because of needing to understand what amounts to the "fine print" in the Current Procedural Terminology (CPT) book code description. It also depends on whether or not the physician subsequently had face-to-face contact with the patient in the hospital. According to the CPT book, "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g. physician's office) all evaluation and management services (E/M) 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 s/he provided in the other sites of service as well as in the inpatient setting." At first, this wording could lead physicians and coders to conclude that their only recourse is to "roll up" the level of service provided in the clinic with the additional documentation necessary to admit a patient to the hospital to determine the code for "Initial Hospital Care", CPT 99221-99223. However, it has been noted that the description in the CPT book under initial hospital care has "fine print" in the statement the "codes are used to report the first hospital inpatient encounter with the patient by the admitting physician." "Encounter" is commonly understood to mean a "face to face" encounter between the physician and patient in the hospital setting. But, what if the physician does not go to the hospital to see the patient on the same date that s/he saw the patient in the clinic? Because a face to face encounter in the hospital did not occur, it would be inappropriate to use any of the "Initial Hospital Care" CPT 99221-99223 codes. Rather, the services of the clinic visit should be billed as "new" or "established" patient office visit on the date seen and the initial hospital service would be billed on a following date when the physician actually sees the patient in the hospital setting.
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