A thanks goes out to the Society of Hospital Medicine's excellent publication The Hospitalist for pointing out a major shift of policy from CMS (pronounced "See A Mess") on how it pays for discharge diagnosis codes 99238 (discharge work took less than 30 minutes) and 99239 (discharge work took greater than 30 minutes). All us docs ( minus the surgeons who get a global 90 day fee) in the hospital patient care business have been instructed in years past that we could only bill the discharge CPT® codes 99238 and 99239 on the actual day of discharge. If you spent 40 minutes working on a discharge on May 1st, and the nursing home wouldn't take the patient because it was "too late in the day" you were stuck with CPT® medical coding using codes 99231, 992332 or 99233 for that day. These codes pay less than the hospital discharge codes.
When the patient was ready to leave the following day, in order for the doc to collect any revenue they would have to have a face to face evaluation with the patient, again, basically to say hi and by and write another note indicating they are O.K. with discharge. It really was quite silly. It also lead to unnecessary billable physician encounters. And voltage drop in information if a new doc came on service the following day. Now, if the patient left before you had a chance to see them again on May 2nd, you got screwed out of collecting the payment for the discharge codes entirely. Unfair by all accounts.
Not so anymore. A major reversal has made its way through CMS.
Not so anymore. A major reversal has made its way through CMS.
CMS has indicated that the physician may bill the discharge diagnosis codes 99238 and 99239 on the day that the discharge work is performed, even if that day is different from the actual day of discharge. For example. If I planned to discharge my patient May 1st and I spent 40 minutes on this complicated discharge process by filling out scripts, medications, making phone calls to specialist and the primary care doc. If I did all that and the patient didn't go because "the van couldn't get here", or "I'm snowed in", or "it's too late in the day", I would be shafted from collecting on a 99238 or 99239 discharge code. I would, in all likely hood be stuck with collecting a follow up code 99232. With the new rules, I could still collect a 99238 or or a 99239 on May 1st, even if the patient didn't discharge until May 2nd.
Hospital Discharge Day Management Service
Hospital Discharge Day Management Services, CPT® code 99238 or 99239 is a face-to- face evaluation and management (E/M) service between the attending physician and the patient. The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner even if the patient is discharged from the facility on a different calendar date. Only one hospital discharge day management service is payable per patient per hospital stay. Only the attending physician of record reports the discharge day management service. Physicians or qualified nonphysician practitioners, other than the attending physician, who have been managing concurrent health care problems not primarily managed by the attending physician, and who are not acting on behalf of the attending physician, shall use Subsequent Hospital Care (CPT® code range 99231 – 99233) for a final visit. Medicare pays for the paperwork of patient discharge day management through the pre-and post- service work of an E/M service.
One thing that isn't clarified, is if CMS allows you to bill a hospital follow up code after a discharge code. For example, if I spent 40 minutes on May 1st doing the discharge work and billed a 99239 (greater than 30 minute discharge), CMS doesn't clarify if I can bill a hospital follow up visit on May 2nd (99231, 99232, or 99233), the day the patient actually leaves the hospital. You can only bill one hospital discharge code per hospital stay, but I couldn't find clarification if they allowed follow up codes to be billed on a date of service after a discharge code. Common sense would say no, that billing a hospital follow up code after a discharge code would just not make sense. But there is a lot about CMS that doesn't make sense. CMS needs to clarify this. Especially since many hospital bylaws state that the attending physician is required to see the patient every calendar day, even if it's just to say hi and by. You never know if the patient's condition has changed from the planned day of discharge on May 1st and the actual day of discharge May 2nd. But assuming your nurses are competent, there should be no reason why a doc would have to see the patient on May 2nd if nothing has changed clinically from the prior day.
This CMS ruling of allowing the discharge codes to be billed on a different calendar day from the day of discharge has big implications for the shift model of hospitalist medicine. And I think it's for the better. A voltage drop in information occurs in any model of care where a hand off occurs. Whether that's the shift model of hospitalist medicine, a specialist being cross covered by a partner for the night call, the week end crew, a new crew of docs coming on service at anytime in any specialty, the nursing staff, the respiratory therapists or anybody who checks out to others as part of their job. Prior to this CMS ruling a very common practice would be as follows. It's Sunday. Nobody goes to a nursing home on a Sunday. They just don't take folks. Nursing homes and banks must belong to the same Closed On Sunday Club. Often times, the plan is to discharge a patient on Monday. The hospitalist may be ending their service for the week on that Sunday. In a production based model of care (RVU), no incentive would exist for the Sunday doc to take care of all the discharge paper work, the discharge summary, contacting the primary care doc. If they can't collect the excess fee generated by the discharge code, there is no incentive financially for them to do it. It's easier to simply "pass the buck" to the doc coming on Monday. Respectful Sunday docs would bite the bullet and do the work, hoping that others would do it for them in return. But it's hard to organize your practice on the hope of others. Now, you don't have to.
Having your Monday partner do your work for you just got a lot less enticing if you can collect the discharge code on Sunday, for a planned Monday discharge. Leaving the new Monday doc out of the loop completely. They don't even need to see the patient. And this can avoid a significant voltage drop of information. No longer do they have to punt the work to their Monday partner They can take the initiative and get paid for doing the right thing.
The new rules say the Sunday doc can get credit for it. I envision a significant improvement in work flow through the hospitalist model by allowing the right people to get credit for the work they do, when they do it. No longer will the Monday doc have to see a patient they know nothing about. No longer will they be subjected to the discharge hassles on a patient they have never met. The Sunday doc should take care of the planned Monday discharge, get credit for it and leave their on coming partner out of it. This is a good thing. One less step in the voltage drop.
CMS also clarified how to bill a patient on the day of discharge, if you didn't actually get to see them while they were alive. If you, the physician, make a determination of death, at the bedside, you can bill a discharge code 99238 or 99239 for that day, even if you don't do the paper work until a later date. This is one of the few times I can say "I see dead people". As CMS says:
CMS also clarified how to bill a patient on the day of discharge, if you didn't actually get to see them while they were alive. If you, the physician, make a determination of death, at the bedside, you can bill a discharge code 99238 or 99239 for that day, even if you don't do the paper work until a later date. This is one of the few times I can say "I see dead people". As CMS says:
Hospital Discharge Management and Death Pronouncement
- Only the physician who personally performs the pronouncement of death shall bill for the face-to-face Hospital Discharge Day Management Service, CPT® code 99238 or 99239.
- The date of the pronouncement shall reflect the calendar date of service on the day it was performed even if the paperwork is delayed to a subsequent date.
One thing CMS needs to change: Allow a physician, other than the attending physician to bill the hospital discharge code. On a frequent basis, the surgeon will admit a patient, do their thing, consult the hospitalist for an assortment of medical issues. The patient may have a very complicated hospital stay. On discharge a HUGE voltage drop of information occurs because, in my experience, discharge summaries don't occur for weeks, and phone calls to primary care docs rarely happen, unless a hospitalist is the attending physician. In our care model we have two universal constants
- Every primary care doc in which we are attending gets a phone call from us on discharge
- A discharge summary is done immediately on discharge with a 24 hour turn around through a special transcription discharge code.
When I am consulted to help evaluate medical issues in complicated surgical patients, I don't get a dime from CMS for spending any effort on the discharge process. I don't get paid for calling primary docs. I don't get paid for doing the discharge. I don't get paid for medication reconciliation. But I should. And here's why. Because in a good system, hospitalists can do a great job of minimizing voltage drop on hospital discharges. I often do the work regardless, because I feel sorry for the primary care doc who gets their surgical patient that had complicating issues and they get to see them in their office in a week, with no hospital summary. No phone call. No explanation. But darnit. I should get paid for doing it. And right now I'm not.
The surgeons get a global fee. They have no incentive to play the documentation game. To provide quick turn around on hospital discharge summaries. To call the primary care doc. To communicate. The financial payment system has created exactly what we are getting. If we start to pay for communication, the great communicators will rise from the hills of salvation to collect their bread and butta.
You can see much more in my free lectures on medical billing and coding.
You can see much more in my free lectures on medical billing and coding.
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