What is the coding scheme when an ER physician refers a patient to another doctor upon admission?

The correct answer describes the standard practice for coding when a patient is admitted to the hospital following a visit to the Emergency Room (ER). In this scenario, the ER physician is responsible for coding the services provided during the ER visit, which typically involves using specific ER codes to reflect the care given, such as evaluation and management codes.

When the patient is subsequently admitted to the hospital by the admitting doctor, this physician will utilize initial inpatient (IP) codes. These codes generally pertain to the services rendered during the admission process, and they begin with the patient's admission to the hospital. This combination of coding ensures that both the ER physician and the admitting doctor are accurately billing for the distinct services they provided during different phases of care, reflecting the continuum from emergency evaluation to inpatient management.

Other choices do not capture the proper coding practices. For example, stating that the ER doctor uses the admission code while the admitting doctor does not does not adequately represent the separation of responsibilities in coding between these two specialties. Similarly, claiming that both the ER and admitting doctor use separate ER codes confuses the nature of the care provided and leads to inaccurate documentation of the patient’s care journey. Lastly, suggesting that the referring physician should not code the visit overlooks the importance of capturing the