Published in the December 2006 issue of Today’s Hospitalist
You might think that coding for discharge services would be fairly straightforward, a matter of checking items off your discharge- planning list and tallying up your time.
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But thanks to the AMA’s code sets, hospitalists need to be able to code for three different types of discharge services. Those services differ from each other based on patient status and include inpatient services; observation with admit and discharge on the same day; and observation with admit and discharge on different calendar days.
Most hospitalists are familiar with the time factors that go into deciding which discharge code to use for inpatient services. But here’s what makes choosing a discharge code for either of the two observation options “the second and third categories on the list “a little tricky: Unlike inpatient services, none of the discharge codes for patients with an observation status depends on the time you spend planning the discharge.
None of the discharge codes for patients with observation status depends on the time you spend planning the discharge.
Here’s a look at the three different discharge options and some common coding mistakes to avoid.
Status 1: Inpatient services
Hospitalists will be most familiar with a discharge from inpatient services. There are two CPT codes to choose from for these services “99238 and 99239 “and the difference between them comes down to time.
If the entire discharge, including all preparation, takes 30 minutes or less, you need to report 99238. If, on the other hand, the process takes more than 30 minutes, you should report 99239.
Here is the list of tasks that the AMA says to include in discharge planning:
- final examination;
- discussion of the hospital stay;
- all the time spent by the discharging physician, as well as time spent by associates, even if that time is not continuous;
- instructions to all relevant caregivers for continuing care;
- preparation of discharge records, including time spent dictating a discharge summary;
- prescriptions; and
- referral forms for any follow-up services.
Depending on patients’ acuity and presentation, you may not have to hit every item on the list. However, you do need to perform a final exam and prepare a discharge record, which can be handwritten or transcribed.
Often the discharging physician or an associate begins preparing a discharge a day in advance. You need to add all that time together to count toward either 99238 or 99239, billing under only one physician’s name for the calendar date that the patient is actually discharged.
When adding up your cumulative time, you can count time spent by members of the physician group but not by therapists or social workers. You also may not include time spent on discharge by either case managers or discharge planners.
Common mistakes to avoid: Make sure you don’t report a discharge date that falls somewhere in the middle of the patient’s hospital stay. If you don’t bill a discharge code on the day of discharge, you can expect to have the claim denied.
And many physicians make the mistake of stating “30 minutes spent discharging patient.” Remember, you must spend more than 30 minutes to justify the higher discharge code of 99239.
Status 2: Admit and discharge on the same calendar day
This category is commonly known as observation status. For this discharge service, you need to choose from the following three CPT codes:
- 99234: observation with a detailed or comprehensive history, a detailed or comprehensive exam, and a straightforward or low level of medical decision-making;
- 99235: observation with a comprehensive history, comprehensive exam and medical decision-making of moderate complexity; or
- 99236: observation with a comprehensive history, comprehensive exam and medical decision-making of high complexity.
Patients would be considered status 2 under the following scenario: They come to the hospital where you perform the necessary history and physical. Based on their presentation or acuity, you opt to hold them to observe their improvement.
When patients are admitted into observation status, they can be located anywhere in the hospital; some hospitals have a separate observation unit, while others keep observation patients in the emergency room. The location is not important, only the fact that the patient has been admitted.
Even if patients are then discharged on the same calendar day, you would have to prepare a discharge record just as for an inpatient services discharge, as well as cover the same tasks on the AMA’s discharge-planning list.
Common mistakes to avoid: When using any of the status 2 discharge codes, do not include either the 99238 or 99239 codes for inpatient services or tie coding levels to time spent in planning.
By the same token, do not add on the discharge code 99217. That code is used only when the discharge takes place on a subsequent day.
For status 2 patients, the discharge code is bundled into the observation service and reflects that added value.
Status 3: Admit and discharge on different calendar days
Patients in this category are also referred to as being on observation status. The difference is that their observation status spans two calendar days, not one.
Just as with status 2 patients, physicians need to document their history and physical and then choose one from three different codes:
- 99218: observation with a detailed or comprehensive history, a detailed or comprehensive exam, and a straightforward or low level of medical decision-making;
- 99219: observation with a comprehensive history, comprehensive exam and medical decision-making of moderate complexity; or
- 99220: observation with a comprehensive history, comprehensive exam and medical decision-making of high complexity.
In addition, you need to bill a discharge code of 99217 for the second calendar day. Keep in mind that you still need to do the discharge tasks as laid out by the AMA, depending on the patient’s acuity.
Common mistakes to avoid: Again, do not factor in time spent preparing the discharge when choosing a discharge code. By reporting a 99238 or 99239 code when discharging a status 3 patient, you can count on the claim being denied for incorrect coding.
At the same time, don’t forget to include the 99217 code, which accounts for the discharge on the subsequent day. Otherwise, insurers will pay for the CPT code you submit “but you may be leaving money on the table.
Tamra McLain is an independent coding consultant in Southern California. E-mail your documentation and coding questions or fax them to 888-202-1601. We’ll answer your questions in a future issue of Today’s Hospitalist.