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Admission and Discharge Services

  1. Is it permissible for a NPP to perform an initial hospital visit (on admission) or a discharge service on behalf of the attending physician, when both are members of the same provider group?

    Answer:
    The provider (or group) who is serving as the attending/admitting physician is responsible for performance of the initial hospital visit and discharge visits. These cannot be performed independently by an NPP member of the physician’s group (the incident to concept does not apply in the hospital setting), unless the NPP holds full admitting privileges at the hospital and will serve in the role of attending physician. Both the initial hospital visit and the discharge visit can be performed on a split/shared basis, in which both the physician and the NPP each perform and document at least one essential face-to-face element of the service, but full performance by the NPP is not permissible as billable to Medicare unless, as stated above, the NPP has admitting privileges. Revised 10/15/2018
     
  2. Is an examination a required element for a discharge service (99217, 99238‒99239) in the hospital setting?

    Answer:
    Discharge services do not necessarily need to include a physical examination. A face-to-face visit may include a discussion with the patient about discharge plans, medication schedules and follow-up care; an examination may be medically appropriate but is not mandatory as part of the service code. Updated 8/29/2017
     
  3. Please clarify correct coding for an initial hospital visit by a consultant provider.

    Answer:
    The admitting (attending) provider bills an initial visit from the 99221‒99223 series with an AI modifier to signify the service as performed by the attending physician. Other initial services by consulting providers are billed with the 99221‒99223 series, without an AI modifier. Updated 8/29/2017
     
  4. What can be billed if a nurse pronounces a patient dead and the attending physician only provides for the discharge summary?

    Answer:
    Only the physician who personally performs the pronouncement of death shall bill for the face-to-face hospital discharge day management service (CPT codes 99238 or 99239). When pronouncement of death is performed by a nurse, the service may not be billed to Medicare, since the nurse is not a Medicare-enrolled provider and no service was performed by the physician. Updated 8/29/2017
     
  5. Please define correct coding for the following: A physician completes discharge services; later in the day, the discharge is cancelled and the patient remains an inpatient for two more days, requiring repeat of discharge services. Is it appropriate for the physician to bill the discharge service for both occasions?

    Answer:
    CMS only approves one discharge service per inpatient admission. The service on the date on which discharge was cancelled may be billed as subsequent hospital care; discharge care rendered on the date of discharge may be billed using the discharge service code(s). Updated 8/29/2017
     
  6. When a provider performs an initial inpatient admission and then transfers care to a specialty provider, can the specialty provider perform the discharge visit?

    Answer:
    Only one hospital discharge day management service is payable per patient per hospital stay. If, after admission, care is transferred to another provider, the provider accepting the responsibility for the patient is considered to be acting as the attending physician and may perform the discharge service. Only the attending physician of record reports the discharge day management service. Providers 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. Updated 6/9/2017
     
  7. When a patient dies, what are the rules for discharge service billing (CPT code 99238 or 99239)?

    Answer:
    The physician who personally performs the face-to-face pronouncement of death may bill for hospital discharge day management service, CPT code 99238 or 99239. The date of the pronouncement should be the calendar date of service on the day it was performed even if the paperwork is delayed to a subsequent date. Updated 6/9/2017
     
  8. If a resident documents the pronouncement of death and the attending confirms the death on his/her documentation, can a discharge code be billed?

    Answer:
    When a resident pronounces death, it cannot be billed by the attending physician who was not present to participate in the service. CMS’s directive is clear in stating that “only the physician who personally performs the pronouncement” can bill for the service. As such, if the attending physician is not present, he/she cannot bill for the CPT code 99238 discharge code. Updated 6/9/2017
     
  9. An attending physician discharges a patient in the morning (e.g., to hospice). The patient dies later that same day prior to discharge, and is pronounced dead by a resident. Can a discharge code be billed? Should the attending update his original discharge note to indicate that the patient was pronounced dead by the resident at the approximate time that is was determined by the resident?

    Answer:
    The attending physician may bill a discharge code for the morning discharge service. Since the pronouncement of death was performed by a resident, no additional billing would be appropriate. The attending physician should update the medical record to reflect the final circumstances. Updated 6/9/2017

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