Hospital Discharge Summary: Insufficient Documentation Causes Most Improper Payments
Insufficient documentation means that something was missing from the medical records. Below is a list of the most common reasons CERT determined there was insufficient documentation that caused improper payments for hospital discharge services:
- Missing documentation that support a face-to-face encounter with the patient;
- Missing time spent on the discharge summary;
- Missing electronic signature or legible signature of the performing provider
The hospital discharge summary codes are to be used to report the total duration of time spent by a physician for final hospital discharge of a patient. The codes include, as appropriate, final examination of the patient (face-to-face encounter), discussion of the hospital stay, even if the time spent by the physician on that date is not continuous, instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms.
- 99238 – Hospital discharge - 30 minute or less
- 99239 – Hospital discharge – more than 30 minutes
- If the code in question is 99239 and the time is not indicated in the medical records, CERT will downcode the service to the lower level code 99238
Related Content
- CMSIOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section30.6.1 (Selection of Level of Evaluation and Management Services) and Section30.6.9.2.B (Hospital Discharge Day Management Services) (1.1 MB)
- CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (Signature Requirements) (592 KB)
Posted 11/13/2017