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Pediatric Coding Alert

Reader Questions:

Don't Report Discharge Without Face-to-Face

Published on Fri May 06, 2011

Question:

Often, I will tell a new mom that she can take her baby home from the hospital the next day provided the newborn continues to stool and feed normally, and to have normal vital signs. The patient is then discharged from the hospital the next day without me seeing the mother or the baby. Our clinic's compliance plan calls for using CMS guidelines across the board. Should we charge the discharge on the hospital discharge day or on the last day I, as the pediatrician, saw the patient?

Missouri Subscriber

Answer:

You should report 99238 (Hospital discharge day management; 30 minutes or less) or 99239 (... more than 30 minutes) on the day that you performed the last face-to-face service with the patient.

"Discharge day management is a face-to-face E/M service between the attending physician and the patient," according to the Medicare Claims Processing Manual Chapter 12, Section 30.6.9.2 (http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf). "The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner even if the patient is discharged from the facility on a different calendar date."

Example: You evaluate a two-day old normal newborn on rounds on Sunday and give the mother take-home instructions, complete discharge paperwork, and instruct the nursing staff to discharge the baby on Monday provided she has no health status changes. The hospital discharges the newborn on Monday.

In this case, you would code discharge day management with 99238 or 99239 when you provided the face-to-face E/M service on Sunday. The hospital would report facility discharge on Monday.

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