Charge Capture for Nutritional Services

cstarnes

This query is related to CPT codes 97802 and 97803. If Clinical Nutrition in the hospital receives a referral and evaluates a patient during an IP admission, the assessment would be the initial assessment and plan of treatment. Charge capture does not occur at our hospital for IPs, so 97802 for the Initial assessment would not be reported/captured. However, when the patient is discharged and the next subsequent Clinical Nutrition visit takes place as OP, is CPT 97803 the appropriate charge to report since the OP assessment is a follow-up and not the initial?

dwilliamsrsi

Based on the information you've provided, CPT 97803 would be the appropriate charge for the follow-up visit. The documentation should reflect that the patient was seen as an inpatient for the initial assessment. If that documentation is in the IP record, just something in the current visit note that states "patient seen for initial assessment as IP on (date)." That ties everything together for the patient's continuity of care, and explains why the initial assessment code is not reflected specifically in billing data (should anyone wonder/question.)