CPT® 99238 and 99239: Billing and Coding Death And Other Scenarios?

A major shift in policy from CMS on how it pays for discharge diagnosis codes 99238 (discharge work of less than or equal to 30 minutes) and 99239 (discharge work of  greater than 30 minutes) has occurred. All us doctors  in the hospital 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 using CPT follow-up medical codes. These codes generally pay less than the hospital discharge codes.  I recommend obtaining a copy of the AMA 2015 CPT standard edition manual for all your CPT as the definitive resource for CPT coding.  I have provided an Amazon link through the picture  below and to the right.

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,  to say hello and goodbye and to write another note indicating they are O.K. with discharge. It really was quite silly. It also lead to unnecessary billable physician encounters and a voltage drop of information if a new doctor came on service the following day.  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, let's say 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 specialists and the primary care physician.   If I did all that discharge planning and the patient did not  go because the nursing home van transport van got a flat tire, the physician used to be stuck billing the hospital follow-up codes for that day. With the new rules, I could still bill the  99238 or or a 99239 on May 1st, even if the patient didn't discharge until May 2nd.  If I decided to stop by and make sure everything was stable with the patient for discharge, can I bill for the May 2nd visit?  Yes.  This Medicare carrier says (in question #3) you can bill a hospital follow up visit, if the services are medically necessary.
As per CMS:
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.
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 weekend 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, the following practice was common: 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, 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 and contacting the primary care doc.  Not anymore.

Leaving the new Monday doctor out of the loop sounds like good medicine.   They don't need to see a patient for discharge that they have never seen, thus avoiding a significant voltage drop of information. The new rules say the Sunday doctor can get credit for work on Sunday but discharged on Monday.   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.

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 other frequent scenario plays out everyday.  How should the physician bill if they provide critical care on the same day the patient dies?  Should they bill for both their critical care and discharge services?  Should they submit payment for 99291 and 99239 on the same calendar date?  I have discussed this scenario in detail at the link provided.  The short answer is no.  You can not bill for both.  You can try but I don't think both will be paid.  

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 large  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.  You can see much more in my free hospital coding lectures.


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