Cardiology Coding Alert

READER QUESTIONS:

Avoid Despair Over Discharge Codes

Question: A cardiologist dictated a discharge summary to occur on one day, and we reported it as such. But the patient experienced a blood pressure drop and was kept overnight, so the patient ended up not leaving until the next day. The cardiologist dictated an "addendum" to the discharge summary from the previous day. How should we report this?


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Answer: You should report a discharge services code (99238-99239), depending on how much time the cardiologist spent caring for the patient and facilitating discharge on the actual day of discharge (the second day). For the first day, simply report a subsequent hospital care code (99231-99233), which you will choose based on the documentation. In the event of an inappropriately reported discharge, you must refund any payments you received and re-report the services correctly.

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