Wiki billing of Discharge from hospital or Swingbed

[mrolf]

If a physician sees the patient on the day of discharge and discusses the plan of care with the patient and their family (face-to-face visit with patient) but does not do an actual physical examination of the patient can we still bill discharge E/M services (99238 or 99315). Please advise. Thanks.

 

[Mojo]

The CPT descriptors note, "The codes include, as appropriate, final examination of the patient, discussion of the hospital stay..." I interpret that statement to mean components that are necessary will be performed. For example, billing 99238 for a death pronouncement wouldn't require instructions for continuing care to all relevant caregivers or preparing prescriptions.

The reality of the situation is healthcare providers perform more care than they document. During the discharge service your physician probably observed and assessed the patient's orientation, mentation, cognitive ability, skin color, respiratory effort and more but without the documentation, there is no way you would know it.