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Answers to your questions about discharge services and add-on codes
When it comes to documentation, don't even think of using a rubber stamp
by Kristy Welker, CPC



Published in the May 2007 issue of Today's Hospitalist.

Several readers have written in with questions related to my past columns, while others have asked about the finer points of billing or documentation for hospitalists. Here are answers to questions about discharge services, add-on codes, review of systems and working with residents.

Discharge services
Q: When discharging a patient, do I have to perform and document a final exam? Or can I state, "Performed at the time of the admission, contained an extensive history, review of systems and physical exam, which will not be repeated at this time. Please see appropriate documentation for
The general consensus is that you need to do a final exam when discharging a patient.

that information."

A: According to coding guidelines, discharge services should include a final examination when appropriate, so the general consensus is that you do need to perform one. Currently, however, there are no guidelines as to the extent of the exam required.

Discharge services should also include a discussion of the hospital stay; instructions for continuing care to all relevant caregivers; and the preparation of discharge records, referral forms and prescriptions.

Q: Do I have to document the time I spend discharging a patient? If, for instance, I spend less than 30 minutes doing the discharge, do I need to state, "15 minutes were spent discharging the patient, discussing ..."?

A: You need to document time spent in discharge services only if you bill a 99239, which is the discharge code to use when you spend more than 30 minutes on discharge services.

According to CPT coding guidelines, you must document the duration of time spent for any time-delineated codes, which include 99239 as well as critical care codes, prolonged services codes, and codes based on counseling and coordination of care.

You do not have to document time spent when billing the discharge code 99238, which you use to designate spending less than 30 minutes. Because there is no specific amount of time that you have to meet to bill that code, you just need to document the discharge services provided.

The 99239 code, on the other hand, has a time threshold you must meet to bill that code, so your documentation has to support the fact that you spent more than 30 minutes.

Add-on codes
Q: Our hospitalist practice provides 24/7 on-site coverage, so different doctors will see the same patient several times over the course of any given day.

One physician in our group will, for example, initiate critical care services and bill CPT code 99291. Later that same calendar day, another group physician may provide additional critical care services, which we bill using the add-on code 99292.

What is the correct way to bill for these multiple services? Should all the services in one day be billed under the second physician, or can we bill each code under the physician who provided the service? We run into this same dilemma with admissions and follow-up visits, where we use the add-on code for prolonged services, 99356.

A: Because the physicians are part of the same group and the same specialty, all of the services provided by different physicians within the group on any one calendar day should be billed under one physician.

Your group needs to decide who gets to bill all the services for each day, using a CPT code and add-on codes for aggregate services provided by more than one doctor. Some groups choose to give that credit to the physician who provided the most amount of work that day for the patient. Others bill based on which physician completed the record.

Such aggregate billing should end up being equal, particularly for physicians whose compensation is based at all on productivity. Some groups internally track physician encounters or RVUs, to distinguish individual services from what has been billed.

Review of systems
Q: I have a question about documenting the review of systems. In your January 2007 column ("What you need to know to document an initial hospital visit"), you state that after doing a complete review of systems, I should document "all other systems negative" after giving the history of the present illness.

In our practice, we have gotten in the habit of writing, "Patient denies any additional complaints/problems." Is this statement sufficient, and will this pass muster if the chart is ever audited?

A: The issue of what is acceptable when indicating that you've done a comprehensive ROS is controversial, and there are many opinions.

According to the Centers for Medicare and Medicaid Services, you need to ask the patient about at least 10 systems and then comment on all pertinent positive and negative systems. That's why using a short-cut statement such as "All other systems negative" may be acceptable.

I do not think, however, that stating "Patient denies any additional complaints/problems" would meet the standard for including a comprehensive review of systems. Why? Because it is not clear from that statement that you asked the patient about the other systems.

Working with residents
Q: I work regularly with residents and invariably, my notes begin with the following notation: "See resident's note for details. I saw and evaluated the patient and agree with the findings and plan of care as documented above." Then I write out my assessment and plan.

This may sound silly, but because I am constantly writing those same two sentences, would it be OK to buy a rubber stamp with those sentences on it, stamp the notes and then write in my assessment?

A: A rubber stamp would definitely not be a good idea. In fact, you should have some charts where you don't agree with the resident's finding and/or care plan, and need to revise.

Using a stamp on every record that says you agree could lead auditors to question either the validity of the documentation or the degree of supervision you are providing.

Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at kristywelker@hotmail.com. We'll try to answer your questions in a future issue of Today's Hospitalist.
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