Discharge day management services (99238-99239) seem unlikely to cause confusion in the physician community; however, continued requests for documentation involving these CPT codes prove the opposite.
Here’s an example of how a billing error might be made for discharge day management services. A patient with diabetes mellitus, hypertension, and chronic kidney disease is stable for discharge. The patient is being transferred to a skilled nursing facility (SNF). Dr. Aardsma prepares the patient for hospital discharge, and Dr. Broxton admits the patient to the SNF later that day. Dr. Aardsma and Dr. Broxton are members of the same group practice, with the same specialty designation. Can both physicians report their services?
Consider the basic billing principles of discharge services: what, who, and when.
Hospital discharge day management codes are used to report the physician’s total duration of time spent preparing the patient for discharge. These 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.1
Hospitalists should report one discharge code per hospitalization, but only when the service occurs after the initial date of admission: 99238, hospital discharge day management, 30 minutes or less; or 99239, hospital discharge day management, more than 30 minutes.1,2 Select one of the two codes, depending upon the cumulative discharge service time provided on the patient’s hospital unit/floor during a single calendar day. Do not count time for services performed outside of the patient’s unit or floor (i.e., calls to the receiving physician/facility made from the physician’s private office) or services performed after the patient physically leaves the hospital.
Physician documentation must refer to the discharge status, as well as other clinically relevant information. Don’t be misled into believing that the presence of a discharge summary alone satisfies documentation requirements. In addition to the discharge groundwork, hospitalists must physically see the patient on the day he or she reports discharge management. Discharge summaries are not always useful in noting the physician’s required face-to-face encounter with the patient. Simply state, “Patient seen and examined by me on discharge day.”
Alternatively, hospitalists can elect to include details of a discharge day exam. Although a final exam isn’t mandatory for billing 99238-99239, it is the best justification of a face-to-face encounter on discharge day. Documentation of the time is required when reporting 99239 (e.g., discharge time >30 minutes). Time isn’t typically included in a discharge summary, and upon post-payment payor review, a claim involving 99239 without documented time in the patient’s medical record might result in either a service reduction to the lower level of care (99238) or a request for payment refund.3 Physicians can document all necessary details in the formal summary or a progress note.