Pediatric Coding Alert

Question: Sometimes our pediatricians tell a new mom she can take her baby home 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 the physician seeing the patient.

Answer: You should report 99238 (Hospital discharge day management; 30 minutes or less) or 99239 (... more than 30 minutes) on the day that the physician 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 (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: A pediatrician evaluates a two-day old normal newborn on rounds on Sunday. The physician gives the mother take-home instructions, completes discharge paperwork, and instructs 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 the physician provided the face-to-face E/M service on Sunday.The hospital would report facility discharge on Monday.