A 5-year-old child, established patient, is admitted to the hospital to rule out sepsis. If cultures are negative and afebrile for 48 hours, discharge home. What E/M category is reported for this visit?

A 5-year-old child, established patient, is admitted to the hospital to rule out sepsis. If cultures are negative and afebrile for 48 hours, discharge home. What E/M category is reported for this visit?

• A. Hospital Inpatient or Observation Care (Including Admission and Discharge services)
• B. Critical Care Services
• C. Emergency Department Services
• D. Initial Hospital Care

Answer: (D)

The main idea is how hospital E/M categories are assigned. When a patient is admitted to the hospital, the encounter on the admission day is coded as Initial Hospital Care, reflecting the first evaluation and management provided for the hospital stay. If the patient stays over multiple days, those later days are coded as Subesequent Hospital Care. Separately, when the patient is discharged, that discharge day is coded with Discharge Day Management. In this scenario, the child was admitted to rule out sepsis, so the visit described corresponds to the initial evaluation and management on the day of admission. The fact that cultures later are negative and the patient is afebrile for 48 hours and then discharged does not change the category of the admission day. The discharge would be a separate service coded at discharge (or a subsequent day code if dealing with ongoing inpatient care), not the initial hospital care on admission.

The main idea is how hospital E/M categories are assigned. When a patient is admitted to the hospital, the encounter on the admission day is coded as Initial Hospital Care, reflecting the first evaluation and management provided for the hospital stay. If the patient stays over multiple days, those later days are coded as Subesequent Hospital Care. Separately, when the patient is discharged, that discharge day is coded with Discharge Day Management.

In this scenario, the child was admitted to rule out sepsis, so the visit described corresponds to the initial evaluation and management on the day of admission. The fact that cultures later are negative and the patient is afebrile for 48 hours and then discharged does not change the category of the admission day. The discharge would be a separate service coded at discharge (or a subsequent day code if dealing with ongoing inpatient care), not the initial hospital care on admission.