Initial Hospital Service Codes and Established Patients

Question:

We are having a disagreement in our coding department. Our cardiologist sees an inpatient at the hospital, but it’s a patient she knows from the office. Should she bill an initial hospital service code or a subsequent hospital service code when she sees this patient, who she knows and has seen many times?

Answer:

Bill an initial hospital service, if her documentation supports it.

The initial hospital service codes are not defined as new or established. Whether the patient is known to the physician isn’t a factor in reporting the code. An initial hospital service code may be billed once per specialty group, per admission. If she sees the patient the next day, or if her same specialty partner sees the patient the next day, bill a subsequent hospital visit. Only the admitting physician may bill the discharge service.

However, CPT has a new rule in 2023 about reporting hospital services when a consultation is performed in anticipation of an admission. If your cardiologist saw the patient in consultation and sent the patient to be admitted by the hospitalist, then use a subsequent visit for the first visit. However, if that is not the case, use the initial hospital services code or inpatient consult code.

See our E/M Services Guide for additional information.

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