Cardiology Coding Alert

See hint 4 to solve a tricky DOS question.

Hospital discharge coding seems simple at first glance, but there are still plenty of potential troublemakers. These five pointers will help you polish your discharge coding skills to ensure you properly represent the services your physicians provide.

1. Start the Selection With the 30-Minute Test

When your physician performs hospital discharge services, you have two codes to choose from:

• 99238 — Hospital discharge day management; 30 minutes or less
• 99239 — ... more than 30 minutes.

As the code descriptors indicate, the choice between the two codes depends on the time your provider spends on the discharge services. Thus, you will look in the documentation for notes about the time spent.

“We teach our faculty physicians and residents to note the time they spent in the record,” says Charlotte T. Tweed, RHIA, CPC, coding auditor, GME interim compliance manager, and privacy officer at Florida Hospital in Orlando. “Documenting the time will meet all contracted insurance requirements. We will always check the chart prior to coding 99239 to verify the time is documented and the qualification has been met.”

Important: If there is no time notation in the discharge service documentation, you must code 99238 rather than 99239. “Currently the default is 99238 and, while not preferable, if no time is documented then it can still be coded,” Tweed explains. “Proper time documentation for all discharge services in the medical record will protect the physician regardless of what the current insurance requirements are or may change to. These requirements do change from time to time depending upon contracts and CMS carriers. Getting in the habit of always noting the time for discharges will protect the physician in every situation.”

What counts? E/M guidelines indicate that you should use the discharge management codes “to report the total duration of time spent by a physician for final hospital discharge of a patient.” Services may include examining the patient, discussing the stay, instructing caregivers on continuous care, and the related paperwork, such as the discharge records, prescriptions, and referral forms, the guidelines state. When you calculate the time involved on discharge day, remember that CPT® says the time doesn’t need to be continuous.

2. Limit Discharge Reporting to the Attending 

Several physicians (or non-physician practitioners) might be involved in a patient’s care, and all might try to bill for the discharge — but only the attending physician should bill for the discharge, according to CMS. So if your physician is not the attending physician, you shouldn’t report 99238 or 99239. “Other physicians seeing the patient would bill a regular hospital day service as appropriate,” Tweed says.

The Medicare Claims Processing Manual states, “Only the attending physician of record reports the discharge day management service. Physicians or qualified non-physician practitioners, other than the attending physician, who have been managing concurrent health care problems not primarily managed by the attending physician, and who are not acting on behalf of the attending physician, shall use Subsequent Hospital Care (CPT® code range 99231-99233) for a final visit” (Chapter 12, Section 30.6.9.2, www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf).

Remember that the admitting physician (also known as the physician of record) should append modifier AI (Principal physician of record) to the applicable admission code to help distinguish from other physicians who might become involved in the patient’s care.

Pointer: The practitioner performing discharge does not necessarily have to be a physician. Presuming all of the rules are met, a non-physician practitioner can bill a discharge. Note the reference to a nonphysician practioner in the Medicare Claims Processing Manual: “The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner.”

Teaching facility note: If your doctors work in a teaching facility pay attention to some special considerations. A “resident physician’s time spent in discharge may not be added to the faculty attending time to determine the level of service for the discharge,” Tweed warns. “The faculty (teaching) physician’s time alone must be documented and used to determine the level of service for the discharge.”

3. Ensure Admission Before Coding Discharge

In various circumstances, a patient may not be eligible for a discharge code.

Example: If the patient never left the emergency room and thus was never admitted as an inpatient, you shouldn’t report a discharge code. Instead, submit the appropriate ED service code (99281-99285, Emergency department visit for the evaluation and management of a patient …).

Another example could be a patient who has been admitted as an inpatient but at the last minute the patient is changed to an observation case. Sometimes the documentation for such changes may be delayed. See the observation discharge code 99217 (Observation care discharge day management [This code is to be utilized to report all services provided to a patient on discharge from “observation status” if the discharge is on other than the initial date of “observation status.” To report services to a patient designated as “observation status” or “inpatient status” and discharged on the same date, use the codes for Observation or Inpatient Care Services (including Admission and Discharge Services, 99234-99236 as appropriate.)]).

“The point of service is always checked to determine if the patient was admitted to inpatient or in observation status,” Tweed says. “99238 and 99239 are only used for inpatient status while 99217 would be used for observation discharge. The status of the patient often changes during the stay so we verify it after discharge prior to billing.”

4. Apply Medicare’s DOS Rule

Suppose your physician sees a patient on Monday and says that if the patient doesn’t have any more vomiting or pain, she can go home the next morning (Tuesday). If the physician doesn’t see the patient on Tuesday, you may wonder when to report the discharge.

Helpful: CMS doesn’t say that the provider must see the patient on the discharge date to bill a discharge code. According to Chapter 12 of the Medicare Claims Processing Manual, “The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified non-physician practitioner even if the patient is discharged from the facility on a different calendar date.”

Most coding analysts agree that the intent of CMS’s change to this section of the manual a few years back was to recognize that in today’s world of discharges happening at all times of the day and night, the work defined by the 99238 and 99239 codes may actually be done the day before the discharge date.

In the example above, the patient’s actual day of discharge is Tuesday, but all of the discharging provider’s work (all of the thinking work to plan for the discharge and to do the discharge orders) was completed on Monday.

Caution: “While allowable as long as the orders, instructions, etc., are done and documented on the date of discharge, we discourage the practice since not all our patients are Medicare,” Tweed warns.

In addition, there may be other reasons the discharge date of service is not the calendar date the patient actually left the hospital, Tweed says. “A few years ago CMS clarified the discharge date of service may be prior to that [date the patient left]. An example would be the physician discharges the patient but due to transportation or other factors the patient may not leave until the following calendar date. The discharge would be on the date of service it was done by the physician not the day the patient physically left the hospital building. While this situation does not happen very often the potential for it to happen is there,” Tweed adds.

5. Watch for Unbreakable CCI Edits

Correct Coding Initiative (CCI) edits, version 19.3, which went into effect Oct. 1, 2013, introduced edits that bundle E/M codes for new and established patient office visits (99201-99205 for new and 99211-99215 for established) as Column 2 codes into hospital discharge services codes (99238-99239). These edits are still in place under version 20.0, which went active on Jan. 1, 2014.

Remember: Codes 99238 and 99239 are used to report all services provided to a patient on the date of discharge, when that date of service is different from the initial date of inpatient status. If you’re reporting observation or inpatient hospital care on the same date as the patient’s admission or discharge, you would choose from codes 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date …).

“The important point is that these new bundling edits cannot be bypassed with a modifier,” says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver, Colo. “If the physician performs the hospital discharge services, he or she could not bill for an office E/M service that was potentially performed later in the day.”