Published in the August 2011 issue of Today’s Hospitalist
MY JUNE COLUMN (“The finer points of billing observation“) prompted several readers to send in additional questions about how to bill and code for discharge services. I’ll use this month’s column to address and clarify those issues.
In our October 2016 article, we ask “Is your documentation as accurate as possible?”
Most of your questions relate to the two most frequent discharge service codes you use, which are for patients who’ve been admitted. These are 99238, hospital discharge day management 30 minutes or less, and 99239, hospital discharge day management more than 30 minutes.
But let’s review some basics for all the hospital-based discharge codes. In addition to 99238 and 99239, you can bill two other discharge codes: 99217 (observation care discharge) and 99234-99236 (observation care services including same-day admit and discharge).
You can’t include services rendered by residents or nurses as part of your cumulative time on discharge.
According to the AMA, the following are generally included (and can be counted toward time billed for discharge) in all three code types listed above:
- 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.
You are not required to document each of these components. And while there’s no absolute requirement for a discharge exam, you typically should perform one because it helps support the requirement that you have a face-to-face discharge encounter with the patient. (My June article failed to stress that face-to-face requirement, so let me clarify that here. Discharge services, like every other service that Medicare pays for, must include a face-to-face encounter with the patient on the date of service.) Discharge records can be handwritten or transcribed.
Related article: Bracing for the Transition to ICD-10 Codes?
Billing an inpatient discharge
When it comes to billing either 99238 or 99239, discharge services should be performed by either the attending physician of record or another physician within that same group. A physician outside your group may perform the discharge only if the patient’s care has been transferred to that physician during the hospital stay.
You may bill only one discharge code under only one physician’s name. The billing date for discharge services should be the date on which the actual face-to-face discharge occurs.
You don’t need to document the amount of time you spend on discharge services if you’re billing 99238, because that code has no time threshold. You are required, however, to document how much time you spend on discharge services when billing 99239.
Your documentation must make it clear that you spent more than 30 minutes on that patient’s discharge. When I audit records, I often find that the documentation doesn’t support the 99239 code selection. Either physicians don’t bother to document the time they spend, or they make the mistake of stating “30 minutes spent discharging patient.” You must spend more than 30 minutes (and say so in your documentation) to satisfy the billing requirements for the higher 99239 reimbursement.
Also remember that when calculating your time, you shouldn’t include any time spent on other services. Your time spent on discharge cannot, for instance, include time spent away from the unit floor or any time spent rounding on the patient the previous day. And you can’t include services rendered by residents or nurses as part of your cumulative time on discharge.
One discharge, one admission?
Let’s review some other basic principles of billing for discharge services. Say you’re discharging a patient from inpatient status and admitting him or her to a rehabilitation facility or another acute-care facility.
You may not bill for both the discharge service and the admission to the new facility if both of those services occur on the same calendar date. In general, physicians may bill (and be paid for) only one evaluation and management (E/M) service per specialty per patient per day. As for reimbursement, admission codes typically pay more than discharge codes. In this scenario, it would be to your advantage to bill the admission code, as long as you perform and document all the required components of that code.
You may, however, perform and bill for both services if you are discharging a patient from the hospital and admitting that patient to a nursing facility (99304-99306) on the same date.
Medicare has also made it clear that you may bill discharge codes when you pronounce a death. To do so, however, you must be the physician who actually makes the pronouncement and you must have had a face-to-face encounter with the patient. You may bill that discharge service only on the date of the actual death.
Inpatient or observation?
One of the most common mistakes I see with billing discharge services is selecting the wrong discharge code for the patient’s status. As I pointed out at the beginning of this article, there are three types of codes you can use for hospital-based discharge services.
Make sure you select the discharge code that corresponds with the patient’s place of service and status. Otherwise, your claim will be denied.
Do not, for example, bill an observation discharge code (99217 or 99234-99236) for a patient who’s been admitted as an inpatient. Insurance companies use edits to ensure that the CPT code you submit for discharge services corresponds to what the hospital reports as the patient’s place of service. If the hospital states that a patient was admitted, the only discharge service code the insurer will accept is 99238 or 99239.
Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at firstname.lastname@example.org. We’ll try to answer your questions in a future issue of Today’s Hospitalist.