Coding hospital discharge visits requires the careful consideration of numerous elements to ensure the coding is completed in a proper manner and the charge results in payment for the services rendered. Among the considerations include the time spent with the patient, the timing of the visit and whether the patient was in fact admitted to the hospital. These key elements are summarized as follows.
Documenting the time spent providing all of the services relating to a patient’s discharge is key to the coding of the discharge visit. If no time is noted in the documentation, only CPT 99238 can be billed. However, if the provider documents more than 30 minutes, the provider can code and bill CPT 99239 for the inpatient discharge service. Furthermore, when documenting the total duration of time spent for the final discharge of the patient, the time spent with the patient does not need to be continuous. Discharge services by the attending physician may include the patient exam, discussion of the stay, instructions for any caregivers on continuous care and any related paperwork such as discharge records, prescriptions and referral forms. By documenting time, you may find the documentation supports CPT 99239 rather than CPT 99238.
As it relates to the date of service, the discharge visit is to be reported on the actual day the physician or qualified non-physician practitioner last visited the patient, even if the patient is being discharged on a different calendar date. Therefore, the discharge service would be billed on the last date the physician performed services for the patient and not on the date the patient physically left the hospital.
Finally, if the patient never left the Emergency Room and was not admitted, a discharge code would not be reported. Instead, the provider would bill the appropriate code for ER services (CPT 99281 - CPT 99285). Similarly, when a patient is admitted as inpatient but the status is changed to observation, the provider would charge CPT 99217 for the discharge services. Lastly, if the patient is admitted and discharged on the same day, the provider would report one code from CPT 99234-99226 for the admission and discharge of both inpatient and outpatient services.
Please don’t hesitate to contact Precision if you have any questions regarding how to properly document and code hospital discharge visits.