Neurosurgery Coding Alert
Face Time Vital When Reporting This Service
Question: I read that when reporting discharge day management service, we must provide and document a face-to-face encounter for that inpatient day. Does that mean that if a provider does not provide a face-to-face service on the day of discharge, he cannot charge an evaluation and management (E/M) service? Virgina Subscriber Answer: The provider cannot report an inpatient service unless a face-to-face encounter occurs on that day. If the provider does not see the patient on the day of discharge, or any other day during the hospitalization, you may not report any E/M service. You should, however, report face-to-face services based on when the direct contact (face-to-face service) occurs. Here’s how: If the provider sees the patient the day prior to discharge, the provider can report the appropriate subsequent hospital care code from 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:A problem focused interval history;A problem focused examination;Medical decision making that is straightforward or of low complexity...) through 99233 (… A detailed interval history; A detailed examination; Medical decision making of high complexity...). If the provider sees the patient on the day of discharge, you may choose the most appropriate code that represents the amount of floor/unit time the provider spends with the patient and other activities directed toward the discharge. For discharge services of 30 minutes or less, use 99238 (Hospital discharge day management; 30 minutes or less). Report discharge services taking more than 30 minutes as 99239 (… more than 30 minutes).
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Face Time Vital When Reporting This Service
Question: I read that when reporting discharge day management service, we must provide and document a [...]
