Neurology & Pain Management Coding Alert

Question: A neurologist visited a patient in follow-up care and we billed 99231. Before midnight, the patient was transferred to acute care. The doctor was required to dictate a discharge summary. Can we bill 99231 and 99238 for the same day and stay within Medicares guidelines?

New York Subscriber

Answer: According to CPT Assistant, hospital discharge day codes 99238-99239 include all the E/M services performed on the day of discharge. It is not appropriate to separately report a subsequent care code (99231-99233) if a discharge is performed on the same day.


Answered by Tiffany Z. Eggers, JD, MPA, policy director/legislative counsel for the American Association of Electrodiagnostic Medicine (AAEM) in Rochester, Minn.; Neil A. Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside; Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.; Melody Mulaik, MSHS, CPC, president and co-founder of Coding Strategies Inc., an Atlanta-based coding and reimbursement firm that supports more than 500 physicians nationwide; and Tammy Chidester, CPC, billing supervisor at Upshur Medical Management Services Inc. in Buckhannon, W.Va.