Practice Economics

Plan for Discharge


 

Discharge planning typically begins at the time of admission. Physicians and hospital staff manage the patient’s acute issues throughout the stay while simultaneously trying to anticipate the patient’s discharge needs. Physicians capture these associated efforts by reporting discharge day management codes 99238 or 99239.

Code Use

Use of discharge day management codes 99238-99239 is reserved for the admitting physician/group, unless a formal transfer of care occurs (e.g., patient is transferred from the intensive care unit by the critical care physician to the medical-surgical floor on the hospitalist’s service).

Code of the Month

Discharge Management

99238: Hospital discharge day management, 30 minutes or less.

99239: Hospital discharge day management, more than 30 minutes.

The hospital discharge day management codes are to be used to report the total time spent by a physician for final hospital discharge of a patient. The codes include, as appropriate:

  • Final examination of the patient;
  • Discussion of the hospital stay, even if the time spent by the physician on that date is not continuous;
  • Instructions for continuing care to all relevant caregivers; and
  • Preparation of discharge records, prescriptions, and referral forms.

Report one discharge code per hospitalization, but only when the service occurs after the initial date of admission. Codes 99238 or 99239 are not permitted for use when the patient is admitted and discharged on the same calendar date. When this occurs, the physician selects from 99221-99223 (initial inpatient care) or 99234-99236 (admission and discharge on the same day). Choose 99234-99238 when the patient stay is eight or more hours on the same calendar day and the insurer accepts these codes.

Documentation must also reflect two components of service: the corresponding elements of both the admission and discharge. Alternately, if the patient stays less than eight hours, or the insurer does not recognize 99234-99236 (admission and discharge on the same day), report 9922x (initial inpatient care) as appropriate.

Don’t mistakenly report discharge services for merely dictating the discharge summary. Discharge day management, as with most payable evaluation and management (E/M) services, requires a face-to-face visit between the physician and the patient on discharge day.

The entire visit need not take place at the bedside and may include other discharge-related elements performed on the patient’s unit/floor such as discussions with other healthcare professionals, patient/caregiver instruction and coordination of follow-up care. The discharge code description indicates that a final examination of the patient is included, but only “as appropriate.” In other words, an exam may not occur, or may not be documented, yet this does not preclude the physician from reporting 99238-99239. However, inclusion of the exam in the discharge day documentation is the best way to justify that a face-to-face service occurred on discharge day. This may be included in the discharge summary or a separate progress note in the medical record.

Code These Cases

Case 1: An otherwise healthy 58-year-old male patient is admitted by the surgical team for a hip fracture. The hospitalist is asked to see the patient postoperatively. The surgeon completes the necessary postoperative check and asks the hospitalist to discharge the patient. What service(s) can the hospitalist report?

The Solution

The hospitalist is not part of the same specialty provider group and so may report subsequent hospital care code 9923x. In order to submit a claim for this service, the hospitalist must not be acting under a formal transfer of care (i.e., the surgeon asks the hospitalist to assume postoperative care of the patient).

Otherwise, the service is considered part of the surgeon’s global package. Either the surgeon and the hospitalist must submit separate claims for their respective portions of care, or the hospitalist must obtain the appropriate portion of the surgical package payment from the surgeon.

Billing for subsequent hospital care (9923x) also requires medical necessity—a reason for the hospitalist’s involvement. The “otherwise healthy” patient may not have medical issues unrelated to the surgery.

If this is the case, the diagnosis code submitted with 9923x involves only the surgical issues already included in the surgical package payment. Therefore, the work involved in discharging the patient becomes an unpaid administrative effort.

Case 2: The hospitalist sees the patient the day before discharge, documenting the patient’s discharge orders and instructions pending negative lab results. The patient leaves the hospital the following day. The hospitalist never sees the patient on that last day but completes all the necessary paperwork. Can the hospitalist report appropriate discharge day management code 99238-99239 on the date before the actual discharge?

The Solution

No. Discharge day management may be reported only on the final day of the hospitalization, and only when the physician sees the patient (i.e., a face-to-face service). Report the service provided the day prior to discharge with the appropriate subsequent hospital care code (99231-99233). No service should be reported on the final day of hospitalization for the above scenario.

Time-Based Service

Discharge day management codes reflect the time accumulated on a calendar date, ending when the patient physically leaves the hospital. Services performed in a location other than the patient’s unit/floor (e.g., dictating the discharge summary from the outpatient office), do not count toward the cumulative time. Additionally, discharge-related services performed by residents, students or ancillary staff (i.e., registered nurses), such as reviewing instructions with the patient, do not count toward the discharge service time.

To support the discharge day management claim, documentation should reference the discharge status and other clinically relevant information. Time is not required when documenting 99238 because this service code constitutes any amount of time up to and including 30 minutes. When reporting 99239, documentation must include the physician’s cumulative service time (more than 30 minutes).

Medicare currently initiates a prepayment review (i.e., request for documentation to review the service prior to any payment consideration) for claims involving 99239. Failure to respond to the prepayment request or failure to include the time component in the documentation often results in claim denial. Payment can be recovered only through the appeal process or claim correction, when applicable.

Rules For Surgery

Surgeons are prohibited from separately reporting inpatient postoperative services related to the surgery, including discharge day management (99238-99239). Additionally, when the surgeon admits a patient to the hospital and discharge services are performed postoperatively by the hospitalist, discharge day management is included in the surgical package.

The reasons are two-fold: If the surgeon transfers the remaining inpatient care to the hospitalist, these discharge services are considered part of the global surgical package.

If no transfer occurs (as the surgeon is typically responsible and paid for all care up to 90 days following surgery), only the admitting physician/group (i.e., the surgeon) may report discharge day management codes 99238-99239.

In the latter scenario, the hospitalist reports subsequent hospital care (99231-99233) for all medically necessary services involving the patient’s medical management, even if provided on the day of discharge.

Pronouncement of Death

One of the most underreported services involves pronouncement of death. A physician who performs this service may qualify to report discharge day management code 99238-99239. To pronounce death, the physician must examine the patient, thus satisfying the face-to-face visit requirement.

Additionally, the physician may have to coordinate the necessary services, speak with family members or other healthcare providers, and fill out the necessary documentation.

If performed on the patient’s unit/floor, these services count toward the cumulative discharge service time. Documentation must include the time (if reporting 99239) as well as the patient’s discharge status and clinically relevant information. Completion of the death certificate alone is not sufficient for billing. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

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