General Surgery Coding Alert

Only one physician can report the discharge service

You should always include hospital discharge services as part of the global surgical package for major procedures. But even in cases when you think the surgeon should be able to bill a separate discharge service (99238-99239), you should be on the lookout for these five problem areas.

Learn more: This is the second in a two-part series on hospital discharge coding. For more information on 99238-99239, see "Add $25 to Your Hospital Discharge Claims," General Surgery Coding Alert, September 2005.

Keep an Eye for Observation Opportunities

Sometimes a patient may not be eligible for a discharge code, says Jennie Horner, CPC, a coder with Southern Ohio Medical Center in Portsmouth, Ohio. This can happen if the patient never left the emergency department (ED) and thus was never admitted as an inpatient.

Solution: In this case, you should use the observation codes (99217-99220) instead of a hospital discharge.

Example: A patient arrives in the ED with several deep facial lacerations after falling from a bicycle and striking his head on the pavement. The surgeon tends to the patient's wounds and places the patient in observation for several hours to monitor his behavior. In this case, you would report the wound repair (for example, 12053, Layer closure of wounds of face, ears, eyelids, nose, lips, and/or mucous membranes; 5.1 cm to 7.5 cm), along with an appropriate-level observation code (such as 99219, Initial observation care, per day, for the evaluation and management of a patient ...). You should include the ED service as a part of the observation care.

One more to watch for: If the patient has a same-day admission and discharge, you would not report separate admission and discharge codes. Instead, you should select observation or inpatient care services (99234-99236). These services include same-day admission and discharge.

Try for Face-to-Face Discharge

Many experts believe that the physician must see the patient face-to-face on the discharge date to bill 99238 (Hospital discharge day management; 30 minutes or less) or 99239 (... more than 30 minutes), says Joan Gilhooly, CHCC, CPC, with Medical Business Resources in Evanston, Ill. So, if the surgeon last saw the patient the night before, she must bill subsequent care (99231-99233).

On the other hand, the CPT code descriptor appears to give some latitude to include only some of the discharge planning elements in 99238. And, you can bill 99238 for the work associated with a patient's death in the hospital, which doesn't necessarily involve a face-to-face visit.
 
Example: Sometimes the surgeon will see a patient in the evening and say that if the patient doesn't have additional symptoms, he can leave in the morning. The surgeon won't see the patient the next day before discharge, so there's a gray area as to whether the physician can bill for discharge planning, Gilhooly says.

Play it safe: Until CMS issues a clarification concerning discharge without a face-to-face meeting, you may be better off billing for subsequent care (99231-99233).

Stick With One E/M Charge per Day

If the patient checks out of the hospital and visits the physician's office later that same date, you should probably not report a separate E/M service. Some physicians have tried to bill for this, but this practice won't wash - unless the afternoon E/M is unrelated to the discharge.

Solution: Assume that the discharge code includes taking care of all the patient's needs postdischarge for that date of service, Gilhooly says.

Watch Your Carrier's Rules

Cahaba GBA, a Part B carrier in Alabama, Georgia and Mississippi, recently posted on its Web site that it expected physicians to list the amount of time they spent with the patient when billing 99238 as well as 99239. Most coding experts (and many carriers) believe that you only need to note time if you're billing 99239 for more than 30 minutes. But Cahaba believes that both 99238 and 99239 are "timed codes."

Solution: Always have your surgeons record the time involved in a hospital discharge, regardless of the duration. Include the time in your submitting documentation.

Only One Physician Can Bill the Discharge

Only one physician can discharge a patient per inpatient stay, regardless of how many physicians provide the patient's care during the hospital stay, says Charol Spaulding, CPC, CPC-H, vice president of Coding Continuum in Tucson, Ariz.

For example: A family practice physician admits the patient and then consults with the surgeon, who follows the patient through the episode of care. Both doctors might try to bill the discharge, Spaulding says.

Solution: If several physicians care for the same patient during an inpatient stay, the admitting physician (in the example above, the family practice physician) can bill for the discharge, Spaulding says. The only exception is if the admitting physician explicitly transferred the patient's care to the other doctor.