Internal Medicine Coding Alert

When a patient is discharged from a hospital and admitted to a nursing facility on the same day, many physicians wrongly assume they can't code both services. But as long as they provide proper documentation, physicians may bill for both.

However, the converse is not true. You cannot code both a nursing-home discharge and a hospital admission when they occur on the same day.

Sound confusing? Perhaps at first, but the policies make more sense once you understand the rationale behind them.

Into the Nursing Home/OUT of the Hospital " Many coders don't realize it, but it's right there in black and white in CPT that you can charge both a hospital discharge and a nursing-home admission on the same day," says Kathy Pride, CPC, CCS-P, HIM Applications Specialist with the San Rafael, Calif.-based QuadraMed.

CPT's instruction to charge both is in the introduction to codes 99301-99303 (Comprehensive nursing facility assessments). In addition, Section 15505.2 (B) of the Medicare Carriers Manual instructs carriers to "pay the hospital discharge code (codes 99238 or 99239) in addition to a nursing facility admission code when they are billed by the same physician with the same date of service."

CPT's and Medicare's acceptance of both codes on the same day recognizes the complexity of admitting a patient to a nursing facility. "There's a lot of paperwork and time involved in a nursing-home admission," Pride says.

This is "separate and distinct work from what the doctor does when discharging the patient from the hospital," says Dennis Stone, MD, MBA, CMD, chief medical officer of HealthEssentials in Louisville, Ky., and a past president of the American Medical Directors Association.

He says the guidelines for 99303 require physicians to take a comprehensive history, perform a comprehensive examination and provide the documentation that nurses need to complete the resident assessment instrument/minimum data set (MDS), which is used to develop a medical plan of care for the patient. CPT states that medical decision-making is of moderate to high complexity.

This is a different set of requirements than for 99238 (Hospital discharge day management; 30 minutes or less) or 99239 ( more than 30 minutes), which report the time the physician spends discharging the patient from the hospital, including discussion of the hospitalization with the patient and preparation of discharge forms. "Many physicians don't want to dictate a separate note for the nursing-home admission," Pride says, but documentation of two distinct services is key to getting paid for both services on the same day.

Stone says physicians won't have trouble documenting 99303 if they perform the comprehensive history, exam and other assessments the code requires. He notes that some physicians avoid those time-consuming tasks by writing, "See hospital history and physical," but that does not meet 99303's requirements. "They (the patient's history and physical) have changed since the patient entered the hospital," he says.

Physicians do not have to physically visit the nursing facility to use the admission code, Stone says. Instead, he says, they can perform and document the history, physical and other elements required for the patient's nursing-home admission while still at the hospital if they wish. But most states require that the physician visit the nursing facility within a certain number of hours or days to document the admission process, Stone says.

For example, suppose an elderly patient who had a stroke is discharged from the hospital to a nursing home for continuing care once the acute condition has stabilized and rehabilitation is ready to begin. The physician spends 35 minutes discussing the hospital stay with the patient and preparing discharge papers. Then he performs the required nursing-facility assessment, which includes a comprehensive history, a comprehensive examination and medical decision-making of moderate to high complexity. Use CPT codes 99239 and 99303.

Sometimes a nursing-home patient develops a complication that requires hospital admission. For example, a patient has a stroke and is clinically unstable or develops pneumonia with unstable vital signs.

The physician may think it is appropriate to code 99315-99316 (Nursing facility discharge services) in addition to a hospital admission, but carriers will not pay for a nursing-home discharge in this case. "The patients are not being discharged from the nursing home; they're being moved to the hospital because something has happened," says Mabel Restuccio, CCS-P, CPC, owner of Restuccio Healthcare Group in the Memphis, Tenn., area.

Any examination and other time spent with the patient at the nursing home prior to hospital admission is included in the hospital admission codes 99221-99223 (Initial hospital care), CPT states in the opening section for those codes. And Medicare says in Section 15505.1 (G) of the MCM: "Instruct physicians that they may not report a nursing facility service and an initial hospital care service on the same day. Payment for the initial hospital care service includes all work performed by the physician in all sites of service on that date."

That last sentence is crucial to understanding why a nursing-home discharge can't be billed in this case. Restuccio says the same policy applies to patients seen in the physician's office, the emergency department or any other location prior to hospital admission.

"Wherever they were seen, it gets rolled into the hospital admission," she says.