Discharge from 61-Inpatient Rehab Hospital - who does the work and who bills?

Clovis, CA
Best answers
I'm going to try to give as much information as possible, without rambling on (but I think that ship has already sailed!).

Background: Three independent doctors see patients at an inpatient Rehab Hospital. They are all of the same specialty, not of the same practice. They all see their assigned patients Monday-Friday as the attending physician. They rotate weekends, and when it's their weekend, they see every single patient in the hospital (we call it "on call", but they do see every patient on Saturday and each patient on Sunday). I work for one of these doctors. The on-call doc is of the same specialty, and working in place of, the attending physician. Most of the patients are Medicare.

Problem: Who gets to bill the discharge, and who does the discharge summary.

A patient is seen on Friday by their assigned provider. They are discharged on Saturday by the "on call" provider. Here is where the argument starts. The doctors say they are not going to do a discharge summary for a patient that is not theirs, that someone else has been seeing for 10 to 30 days. Often, the assigned provider has done most of the discharge work on Friday (doing orders, signing prescriptions, etc.).

My position is, the discharge is billed by the person doing the work, including the face-to-face time, on the day the face-to-face work is done. If the work is done on Friday, then the official discharge is Friday, even if the patient doesn't leave. Whoever pops their head in on Saturday and waves goodbye is doing a freebie. The assigned doc bills the discharge with a date of service of Friday.

It gets wonky when the discharge is Sunday. You can't do the work of a Sunday discharge on a Friday. The doctors say "everyone does it this way" and I roll my eyes and sigh.

I see this as two separate issues, although I admit that I am in the dark here. 1, I see this as from the facility side (who I do not work for), and what is required of a hospital (having a discharge summary with all of the required elements). 2, I see it from the physician side, of who is doing what work when, and who is billing.

Does the discharge summary that is required on the hospital side have to be the same discharge summary that is required by Medicare to bill a 99238/99239?

Example 1: My Doc is on call for everyone from December 21 to December 25. His patient is discharged by someone else on December 26. When he returned in January 2020, he dictated a discharge summary, with the heading being: Admit Date-Dec 10, 2019; Discharge Date-Dec 26, 2019. I am thinking that the discharge summary, for the hospital, needs to say that he did NOT see the patient on December 26 (he was not even in town that day). To me, it looks like he saw the patient on 12/26/19. Does the doc who saw the patient on Dec 26 just bill a hospital followup 99231/99232/99233, since they are not going to dictate a full discharge summary? And in this case, no one bills the discharge, and my doc loses out on the additional revenue of the discharge code (which is perfectly fine with me, I am 100% on the side of what is right, not what is more money).

Example 2: My Doc sees his patient on a Friday. He does the work of the discharge (home health orders, prescriptions, etc.). The patient stays the night because they are not ready to leave for medical reasons. The patient is discharged on Saturday by the on-call physician. I say that the on-call physician bills for Saturday, and my doc dictates a discharge summary on Monday when he returns, for the hospital. I also say that just like Example 1, no one bills a discharge code.

Example3: The same as Example 2, except the patient stays Friday night for convenience reasons. In this case, I say my Doc dictates the discharge summary on Friday, bills the discharge on Friday, and whoever actually discharges them on Saturday (stops in, how ya doing, ready to leave yet?, etc.) is doing a freebie with no billing.

Example 4, which I see as pretty much the same as Example 1: My doc sees his patient on Friday. The patient is discharged on Sunday by the on-call doctor. Who bills the discharge code and what is the appropriate documentation to bill that, and who does the work of the discharge? Since the on-call docs are REFUSING to dictate a full discharge summary on a patient that is not theirs, that does not appear to be an option. I may be able to convince them to change if the experts can point out documentation that says otherwise, but I doubt it. My doc dictates the discharge summary for the hospital on Monday. I say his dictation is part of what has to be done, and no one will be billed for it, and the discharging doctor bills a followup with followup documentation, saying the patient is leaving that day (Sunday).

Everything I have found says only an attending can bill a discharge; if someone else discharges the patient, unless they are working in place of the attending, they bill a followup not a discharge. From that, I extrapolate that if someone IS working in place of the attending, then that doctor DOES bill the discharge. But again, only if they do the work.