Hospital Discharge Day Services
February 12th, 2009 - Codapedia Editor
Use codes 99238 or 99239 for services provided to a patient being discharged from inpatient status in the hospital. These codes include all of the work performed on the calendar day to discharge a patient, including the exam, discussion with the patient and caregivers, and discharge paperwork. They do not have specific history, exam or medical decision making requirements.
The first code, 99238, is for a discharge that takes 30 minutes or less. Include in that time all discharge day activities, not just face-to-face time. The second code, 99239, is for discharge day management that takes 30 or more minutes. Document time in the discharge summary. If you dictate the discharge summary, and note the time in the written progress note only, ask yourself this question: if a payer asks for the discharge summary, will your Health Information Department print the discharge summary or go and find the paper record and copy what you wrote? In most cases, they will re-print the discharge summary. Document time there!
Only one physician may be paid for discharge day management. Physicians of other specialties who see the patient that day should report/bill for a subsequent hospital visit.
A physician may bill for discharge from the hospital and admission to a nursing facility on the same calendar date, if the physician saw the patient in both locations and performed and documented the services required for both. For the discharge, it is the discharge summary (along with the other work.) For the admission to the nursing home, it is an admission service at the nursing home. See the Codapedia article on nursing home services.
Sometimes, a physician sees the patient the day prior to discharge, and does most of the work of the discharge. Perhaps that visit occurs on a Friday. The next day, the physician or the physician's partner, provides a less extensive service. Can the physician bill for the discharge on Friday and a subsequent hospital visit on Saturday? No. All hospitals require that the patient is seen both days, so bill a subsequent hospital visit on Friday, and the discharge on Saturday.
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
Latest articles: (any category)COVID Vaccine Coding Changes as of November 1, 2023October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.Medicare Guidance Changes for E/M ServicesOctober 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....Can We Score Interpretation of an EKG Towards E/M Medical Decision Making?October 10th, 2023 - Aimee Wilcox
When EKGs are performed in the facility setting or even in the physician's office, what are the requirements for reporting the service and who gets credit for scoring data points for Evaluation and Management (E/M) medical decision making (MDM)? Let's take a look at a few coding scenarios related to EKG services to get a better understanding of why this can be problematic.Accurately Reporting Signs and Symptoms with ICD-10-CM CodesOctober 5th, 2023 - Aimee Wilcox
Coders often find themselves unsure of when to report a sign or symptom code documented in the medical record. Some coders find their organization has an EHR that requires a working diagnosis, which is usually a sign or symptom, be entered to order a test or diagnostic study or image. Understanding the guidelines surrounding when signs and symptoms should be reported is the first step in correct coding so let's take a look at some scenarios.The 2024 ICD-10-CM Updates Include New Codes for Reporting Metabolic Disorders and Insulin ResistanceSeptember 19th, 2023 - Aimee Wilcox
Diabetes is a chronic disease that just seems to consistently be increasing instead of improving resulting in a constant endeavor by medical researchers to identify causal effects and possible treatments. One underlying or precipitating condition that scientists have identified as a precipitating factor in the development of diabetes is insulin resistance, which is a known metabolic disorder. As data becomes available through claims reporting, additional code options become possible with ICD-10-CM.Documenting and Reporting Postoperative VisitsSeptember 12th, 2023 - Aimee Wilcox
Sometimes we receive questions regarding documentation requirements for specific codes or coding requirements and we respond with information and resources to support our answers. The following question was recently submitted: Are providers required to report postoperative services on claims using 99024, especially if there is no payment for that service? What documentation is required if you are reporting an unrelated Evaluation and Management (E/M) service by the same physician during the postoperative period? Understanding Gastroesophageal Reflux Disease and ICD-10-CM CodingAugust 22nd, 2023 - Aimee Wilcox
Gastroesophageal reflux disease or GERD for short, is a disease that impacts millions of Americans on a weekly basis. Symptoms are uncomfortable, as are some of the tests used to diagnose it, but understanding the disease, tests, and treatments helps us better understand how to code the disease using ICD-10-CM codes.