You Be the Billing Expert:
Discharge With No Face-to-Face
Published on Mon Jan 17, 2011
Question: A hospitalist dictates an initial hospital visit (admit) and a discharge within the same note. She dictates "anticipated stay 2-3 days, if XYZ then discharge ..." The patient was admitted Day 1 then discharged Day 2. The hospitalist only saw the patient on Day 1. Can we bill the admission on Day 1 and the discharge on Day 2? If we cannot, do we only charge the admission? I am unsure because there was no face-to-face on the day of discharge and I cannot use the same day admit/discharge because the patient stayed two days.Answer: You should only bill the admission. Since your hospitalist did not perform a face-to-face service for the discharge, and there was no discharge planning and no instruction to the patient, you cannot also bill the discharge. The discharge hypothesis that the hospitalist dictated inthe admission note becomes part of the medical decision making (MDM) [...]