Orthopedic Coding Alert

Question: I read "When reporting discharge day management service, you must provide and document a face-to-face encounter for that inpatient day." Does that mean that if an orthopedic surgeon does not provide a face-to-face service on the day of discharge, he cannot charge an E/M service?

Wisconsin Subscriber

Answer: The doctor cannot report an inpatient service unless a face-toface encounter occurs on that day. If the physician does not see the patient on the day of discharge, or any other day during the hospitalization, he may not report any E/M service. You should, however, report face-to-face services based on when the direct contact (face-to-face service) occurs. Here's how:

1. If the physician sees the patient the day prior to discharge, the physician can report the appropriate subsequent hospital care code (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...).

2. If the physician sees the patient on the day of discharge, he may choose the most appropriate code that represents the amount of floor/unit time the physician spends with the patient and other activities directed toward the discharge. For discharge services of 30 minutes or less, use 99238 (Hospital discharge day management; 30 minutes or less). Report discharge services taking more than 30 minutes as 99239 (... more than 30 minutes). The time spent with the patient and floor time must be documented in the chart along with what was done during that time. Keep in mind that if these services are performed during the postoperative global period of a procedure performed by the same provider, these would not be separately reportable.