Neurology & Pain Management Coding Alert

Question: When our physician discharges a patient, should we bill a hospital follow-up visit and a discharge code, or does the follow-up visit include discharge?

Iowa Subscriber

Answer: The correct answer depends on how the discharge takes place and what services your physician has completed for the patient.

If your physician discharges the patient directly from the hospital, code it as a discharge with 99238 (Hospital discharge day management; 30 minutes or less) or 99239 (... more than 30 minutes).

Exception: If your neurologist admits the patient as an inpatient and discharges her on the same day, report 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date ...) instead.

If your neurologist has completed his part of the treatment but the patient remains in the hospital, report your physician's care as a subsequent visit with 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...).