First Patient Encounter

Question:

I saw a new patient in the outpatient clinic several weeks ago. Now, the patient has been admitted to the hospital. The admitting physician has asked me to see the patient again for that same condition. This is my first time seeing them in the hospital for an inpatient visit. What EM code do I bill for this visit?

Answer:

The E/M code for an initial inpatient visit, regardless of whether the patient was new or established to you, would be billed with either an inpatient consultation code (99252-99255) or an initial hospital code (99221, 99222, 99223 ) with the appropriate level based on MDM or Time.

*This response is based on the best information available as of 5/22/25.

E/M Level When Patient is Non-compliant With Treatment Advice

Question:

An established patient presents to my office with severe exacerbation of an existing condition, and I recommend they be urgently transferred to the ER for admission. The patient refuses and prefers to leave against my medical advice. May I still bill a level 5 E/M for a high level problem that requires hospitalization and urgent intervention?

Answer:

Yes. If a visit MDM would equate to a level 5 visit (e.g. 99215) based on the presenting problem (severe exacerbation) and risk (urgent admission with intervention), patient non-compliance with a provider’s medical recommendations does not preclude the provider from billing the appropriate level E/M.

*This response is based on the best information available as of 5/8/25.

E/M for an Acute Problem

Question:

How do we code for a new patient seen in the office with RUQ upper quadrant discomfort with suspected cholecystitis and an order for ultrasound?

Answer:

A new patient with an acute problem (or “suspected” may be viewed as undiagnosed), with minimal data (order) and minimal/low risk for the ultrasound, would be 99203.

*This response is based on the best information available as of 4/24/25.

Laparoscopic Mobilization of Splenic Flexure With Open Colectomy

Question:

Our provider began a laparoscopic procedure for colectomy and completed the mobilization of the splenic flexure laparoscopically, but then needed to convert to an open procedure to perform the colectomy. What is the correct coding for laparoscopic mobilization of the splenic flexure with open colectomy?

Answer:

When a laparoscopic procedure is converted to an open procedure, you can only code for the open procedure, so in this case, only code for the appropriate open colectomy code; the laparoscopic mobilization of the splenic flexure is not separately billable.

*This response is based on the best information available as of 4/10/25.

Inpatient Consultation Coding for Medicare

Question:

If you see a Medicare patient for the first time in the hospital as an inpatient consultation, what code would you bill for the EM?

Answer:

The EM would be reported as an Initial hospital or observational care codes (99221-99223) with the appropriate level based on MDM or Time. Medicare does not allow payment for inpatient consultation codes 99252-99255.

*This response is based on the best information available as of 3/27/25.

Esophageal Sphincter Augmentation for GERD

Question:

How is esophageal sphincter augmentation for GERD reported?

Answer:

Report CPT code 43284 for laparoscopic placement of the augmentation device (i.e. magnetic band). CPT code 43285 is reported for subsequent removal of the device.

*This response is based on the best information available as of 3/13/25.