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Hospital Discharge Exam Requirements

Janet Posted Fri 05th of July, 2013 17:02:25 PM

Does CMS require the physician to perform a physical exam on the day of discharge when he bills '99238'.
The physician makes the decision to discharge the patient on the same day he sees the patient and the patient is discharged that same day.

SuperCoder Answered Fri 05th of July, 2013 17:58:17 PM

Physician need not necessarily take the decision to discharge th ePt. on the date of discharge. In many cases, physician decides 1 day in advance to release the Pt. the next day. Sometimes he can decide that on the same day too. Whichever day it's, when the decision is taken, code 99238-99239 are time based. Physican should clearly document the discharge Dx, course of medicine/treatment and any other exam if he has performed on the day of discharge. Performing a physical examination is not mandatory. The code also doe snot require any PE points to count for a particular level of PE.

Janet Posted Fri 05th of July, 2013 18:08:42 PM

Novitas is our Medicare MAC. One of our coders attended a webinar regarding Discharge coding. The coder said that Novitas made a statement that a physical exam must be documented when billing 99238. I can't find anything that says an exam is mandatory.

SuperCoder Answered Fri 05th of July, 2013 18:44:52 PM

Do not report 99238-99239 when the patient is admitted and discharged on the same calendar date. When this occurs, the physician selects from 99221-99223 (initial inpatient care) or 99234-99236 (admission and discharge on the same day). Choose 99234-99238 when the patient stay is >8 hours on the same calendar day and the insurer accepts these codes. Documentation must reflect two components of service: the corresponding elements of both the admission and discharge, and the duration of time the patient spent in the hospital. Alternately, if the patient stay is <8 hours, or the insurer does not recognize 99234-99236 (admission and discharge on the same day), report only initial inpatient care (99221-99223) as appropriate.

SuperCoder Answered Fri 05th of July, 2013 18:47:37 PM

Physician documentation must refer to the discharge status, as well as other clinically relevant information. Don’t be misled into believing that the presence of a discharge summary alone satisfies documentation requirements. In addition to the discharge groundwork, hospitalists must physically see the patient on the day he or she reports discharge management. Discharge summaries are not always useful in noting the physician’s required face-to-face encounter with the patient. Simply state, “Patient seen and examined by me on discharge day.”

Alternatively, hospitalists can elect to include details of a discharge day exam. Although a final exam isn’t mandatory for billing 99238-99239, it is the best justification of a face-to-face encounter on discharge day. Documentation of the time is required when reporting 99239 (e.g., discharge time >30 minutes). Time isn’t typically included in a discharge summary, and upon post-payment payor review, a claim involving 99239 without documented time in the patient’s medical record might result in either a service reduction to the lower level of care (99238) or a request for payment refund.3 Physicians can document all necessary details in the formal summary or a progress note.

Janet Posted Fri 05th of July, 2013 19:27:51 PM

Thank you so very much. Great explanation!

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