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2nd time posting....please help!

  1. #1
    Exclamation 2nd time posting....please help!
    Medical Coding Books
    Acute discharge from Rehab hospital


    I have a physician who is turning in discharge summaries for patients who are acutely discharged from the rehab hospital for one reason or another (like chest pain, LOC). The problem is, he's dictating these around a month later, and when I go into the patient's medical record and look at the progress notes, I don't see any documentation of the physician actually seeing the patient that day. I'm thinking this dictation is just a requirement of the Rehab Hospital because our physicians are usually the admitting doctors. Am I right to tell this physician that there is no way we can bill for these discharges? I just want some back up on this answer...thanks!!

  2. #2
    Lafayette, LA
    Default Discharge
    Unless the provider saw the patient on the day of discharge, no they may not bill. It very well may be a facility requirement, not uncommon. But for your doctor to recieve credit he will need to go a step further and see the patient.

    Discharge Day Management
    Hospital discharge day management (CPT 99238-99239) is a face-to-face E/M service between the attending physician and the patient. Document the date of the actual physician visit even if the patient is discharged from the facility on a different date.1 Documentation must substantiate this personal patient encounter.

    A physician can choose to record the face-to-face encounter in a handwritten progress note or make note of it in the formal discharge summary. When relying solely upon the dictated summary, physicians often fail to identify personal contact with the patient. Although an examination need only be performed “as appropriate” on the day of discharge, it is the best indicator of a face-to-face encounter. Such statements as “Upon discharge, the patient appeared well, vital signs stable, lungs clear” or “Patient seen and examined by me on discharge day” clearly illustrate this service.

    It is important to note that only the attending physician of record reports the discharge day management service. Physicians or qualified non-physician practitioners (NPPs), other than the attending physician, who have been managing concurrent healthcare problems not primarily managed by the attending physician and who are not acting on behalf of the attending physician should use subsequent hospital care codes (99231-99233) for a final visit.2

    Good luck hope this helps
    Belinda Keeling, CPC, CANPC

  3. #3
    Yes, that helps back up my answer...Thank you!!

  4. #4
    Daytona Beach, FL
    Belinda -

    can you tell me where you found the documentation you provided? I have posted a question in regards to what documentation is required to bill a discharge and this supports the theory that an exam does not need to be documented, but I need to know the source to show this to my supervisor who says she has information to the contrary - that an exam needs to be documented.

    Jodi Dibble, CPC

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