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hospital discharge

  1. Question hospital discharge
    Medical Coding Books
    Hi to all,
    I have a document stating a "Discharge Summary Under 48 hrs" , I know the E/M code of 99238 & 99239, but the documentation only has the Final Dx, Operation Done (on the Date of Admission), Discharge Meds, & Discharge Instructions, i don't have enough data to come up with the right E/M for it. Would i settle for the for the discharge E/M codes or is there other E/M that would best describe the encounter? need your opinion anyone.
    Thank you:

  2. Default
    If the patient was inpt status you would bill with 99238. To bill 99239 the time spent has to be 30 minutes or more and the time has to be documented. If the patient was outpt status then the observation discharge code 99217 may be the appropriate code to use.

  3. #3
    Hmmm, I have always been told that you cannot bill based on a discharge sumamry, you need to have a note specific to the visit that promts the charge....
    Do you have any additional documentation?
    Karolina, CPC, CPMA, CEMC

  4. Smile hospital discharge
    Hi deeva456 & Karolina,

    Thank for you're reply, I do appreciate it ! the status of the Pt was in-Patient and the other documentation that i have is the "procedure report" which was done on the day of admission, and a "History and Physical 24 hour update" which only states that findings have not change, nothing else, should i ask again from the facility more documentation on the period of admission up to discharge?

    Again thank you very much for the help deeva456 & Karolina, hope to hear from the both you soon.

    take care

  5. #5
    Milwaukee WI
    Default Global to procedure
    Depending on the global days for the procedure the discharge management (an E/M code) may be global to the operation.

    F Tessa Bartels, CPC, CEMC

  6. Question
    Quote Originally Posted by FTessaBartels View Post
    Depending on the global days for the procedure the discharge management (an E/M code) may be global to the operation.

    F Tessa Bartels, CPC, CEMC
    Hi FTessaBartels,
    what you mean by it? , if i'll be coming up with a discharge E/M code, do i have to use a modifier to separate it from the global days for the procedure? thank you hope to hear from you soon.

  7. #7
    Milwaukee WI
    Default Who is discharging patient?
    Most procedures carry some global days ... 10 days for minor procedures (e.g. I&D); 90 days for major procedures (e.g. appendectomy). The global days include any/all E/M services associated with the underlying reason for the procedure.

    So, if your sugeon was the admitting physician (and, therefore, the discharging physician), and the procedure performed has global days associated with it, then, s/he cannot charge for any E/M services that fall within the global period. Discharge Day Management codes are E/M services.

    You CANNOT bill out a discharge (or any other E/M) postoperatively for the surgeon.

    I hope I've explained that well.

    F Tessa Bartels, CPC, CEMC

  8. Smile Hospital Discharge
    Hi to all,
    I would like to thank everyone how posted their opinions and comments, i really appreciate all your help, in making me more understand the topic. and i do hope to hear/read all your wonderful and very educating opinions and comments, not just to my queries but to all the queries of all the members of this association. extending my greetings to Deeva456, Karolina, & FTessaBartels I Thank You from the bottom of my heart.


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