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• W4301626384 abstract "Many physicians do not report their observation or hospital discharge day services with the appropriate codes. Discharge day management should not be reported with subsequent-day hospital care codes because these codes (99231–99233, 99433) do not accurately reflect the actual services that are provided.Hospital discharge services should be reported by the attending physician who provides discharge management services to a patient on a day separate from the initial hospital or observation day management. The discharge management codes (99217, 99238, 99239) are differentiated by the place of service (observation or inpatient hospital) and the extent of the services provided. These are global services; they include all evaluation and management (E/M) services provided during a calendar day. Any procedures performed on the same day of service should be reported separately. Discharge day management services do not require the performance of the E/M key components (history, physical examination, medical decision-making). However, the codes do include specific criteria for reporting.99217 Observation care discharge managementCode 99217 is used to report the discharge management (on a day other than the observation admission) of the patient who is designated an observation status patient. (Observation services are provided to patients who require monitoring for possible inpatient admission or transfer; the designation of observation versus inpatient status is dependent on the patient's diagnosis[es] and severity of illness. The hospital assigns the patient status. It is important for the physician to report the service according to that status.)This service includes the final examination of the patient, discussion of the hospital stay, instructions for continuing care, and preparation of the discharge records. The service requires a face-to-face physician-patient encounter in the observation setting. CPT has not assigned a typical time to code 99217.99238 Hospital discharge day management; 30 minutes or less99239 Hospital discharge day management; more than 30 minutesCodes 99238 and 99239 are used to report the discharge management of the inpatient when the service is performed on a day other than the day of admission. A face-to-face physician-patient encounter in the hospital is required. The selection of the code is based on the total duration spent by the physician to provide the final examination of the patient, discussion of the hospital stay, patient or family counseling, instructions for continuing care to all relevant caregivers, and preparation of referral forms, prescriptions, and the final discharge records. The time spent performing discharge management does not have to be continuous. However, because these are time-based services, the time spent in discharge activities must be documented in the medical record when reporting code 99239. It should also be noted that codes 99238 or 99239 are used to report the discharge management of newborns and may be used to report discharge services provided to patients who die during their hospital stay.If the patient is not seen on the day of discharge but the previous day's services include a face-to-face patient visit in the hospital with, as appropriate, the examination, counseling, and instructions for care pending confirmation of anticipated clinical stability, the discharge service code may be reported for the services provided on the previous day. Also, if a physician sees a patient during rounds in the morning then discharges the patient later on the same day via a telephone order, that day's service would be reported as discharge day management using the appropriate code based on the place of service or time spent in providing the services.If a patient other than a normal newborn is admitted and discharged on the same date of service, codes 99234–99236(observation or inpatient hospital admission and discharge) are reported. The selection of these codes is based on the performance and documentation of all 3 key components (history, physical examination, medical decision-making). Code 99435 would be reported when a normal newborn is admitted and discharged from the hospital on the same day. This code does not require the performance of key components. Typical times are not published by CPT for these services.Tip: Keep in mind that the hospital billing may reflect a different day of discharge. Hospital billing requirements are different from coding and billing requirements for physician services and your claim may not match the facility's claim. However, most payers do not question the dates of service if reported appropriately.Remember that only the attending physician can report the discharge day management services. Concurrent care services that are provided by a different physician (different practice or different specialty within the same group practice) may be reported using the appropriate subsequent hospital care code (ie, 99231–99233). Also, discharge day management codes are not reported when a patient is transferred. Instead, the appropriate subsequent hospital care codes (eg, subsequent hospital care, critical care) should be reported.The Medicare relative value units (RVUs) for discharge management services reflect the time and work of providing these services. Note the difference in RVUs for subsequent hospital care services and discharge management services in the Table.Make sure that the observation (99217) and inpatient hospital discharge codes (99238 and 99239) are listed on your encounter form. Review your utilization reports to see if these codes are being reported and at what level. Perform a random review of hospital progress notes to be certain that documentation supports the level of service reported. Educate all physicians and staff about the coding guidelines and use of these codes." @default.
• W4301626384 created "2022-10-05" @default.
• W4301626384 date "2007-05-01" @default.
• W4301626384 modified "2023-10-04" @default.
• W4301626384 title "Hospital Discharge" @default.
• W4301626384 doi "https://doi.org/10.1542/pcco_book037_document002" @default.
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