Frequently Asked Questions

Billing Questions:

The discharge day management service is billed under the actual discharge date. The medical records should clearly state the date of the actual discharge, and also indicate that the dictation was made on the following date.

The Centers for Medicare and Medicaid Services (CMS) advises that according to established legal principles, an individual is not considered deceased until there has been official pronouncement of death. Reasonable and necessary medical services rendered up to and including pronouncement of death by a physician are covered diagnostic or therapeutic services.

Hospital discharge day management codes 99238 (30 minutes or less) and 99239 (more than 30 minutes) are time based so it is imperative that the medical documentation reflect the total time spent by a physician during the discharge of a patient. The codes include, as appropriate, final examination of the patient, 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.

Yes, an initial inpatient visit may be billed. Medicare payment for the initial hospital visit includes all services provided to the patient on the date of admission by that physician, regardless of the site of service.  The physician may not bill an initial observation care code or an observation discharge management code for services on the date that he or she admits the patient to inpatient status.

Documentation Questions:

Credit may be taken only if the physician includes the documentation from the previous visit.