- Evaluation and Management Services
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FAQs
- Admission and Discharge Services
- Advanced Care Planning
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- Related Articles
Admission and Discharge Services
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Is it permissible for an NPP to perform an initial hospital admission or discharge service on behalf of the attending physician, or on a split/shared basis, when both are members of the same provider group?
Answer: The physician who is serving as the attending/admitting provider is responsible for the initial hospital visit (CPTs 99221-99223) on admission. The service may be split/shared between the attending physician and a NPP member of the group, with each provider documenting their contribution to the service. In these instances, the attending physician must fulfill the role of the substantive/billing provider and add modifier AI to the service on the claim. NPP claims with modifier AI will not be processed for payment. The attending physician is also responsible for the discharge service, which may also be performed on a split/shared basis.
- When a patient is placed in observation or inpatient status and discharged from that status on the same date of service, what is the appropriate billing protocol?
Answer: In these situations, for both observation and inpatient status, services are coded with the 99234-99236 set of codes. Discharge service is not separately billable in this scenario, since the codes represent both admission and discharge phases of care.
- Is the 99234-99236 code set appropriate for both the attending physician and a consultant(s) who sees the patient during a same-day admission and discharge scenario?
Answer: Only the attending physician bills with the 99234-99236 code set; consultations performed during same-day scenarios are billed as follows:- Consultants for patients in same day admission/ discharge for patients receiving outpatient observation services: bill outpatient/office code set 99202–99215.
- Consultants for patients in same day admission/discharge for patients in inpatient status: bill inpatient code set 99221–99223/99231–99233.
- What requirements apply to the attending physician who treats the patient during a same-day admission and discharge service?
Answer: The attending physician (or a same-specialty group member) must perform at least two face-to-face encounters with the patient on the date of service. One of these encounters must reflect an admission service and one must reflect a discharge service. Face-to-face encounters with a resident during the stay do not fulfill this requirement, which is the responsibility of the attending physician.
- Please define timeframe limits that apply to 99234–99236.
Answer: In order to bill with the 99234–99236 series, the patient must have been in the facility, either receiving observation services or in inpatient status, or a combination of the two, for a period of eight hours on a date of service. Patient stays of less than eight hours may be billed using the initial care code set of 99221–99223.
When services exceed 24 hours, they are billed with the 99221–99223, 99231–99233 and 99238-99239 code sets, allowing for separate claims for admission, subsequent care and discharge services.
- Are the same-day admission and discharge services billable when the patient is transferred on that date to another facility?
Answer: Yes, these services may still be billed when discharge is followed by transfer to another facility.
- Do prolonged service codes G0316 and G0317 apply to discharge services?
Answer: The prolonged service codes G0316 and G0317 are not applicable to discharge services in the inpatient or SNF setting.
- If time is not documented for CPT code 99238 (hospital discharge day management), what is the appropriate CPT code to bill? Is it acceptable to use 99238 when time is not documented, or should the provider use a subsequent hospital day E/M code (that is supported by documentation) – 99231–99233?
Answer: CPT 99238 describes a discharge service of up to 30 minutes duration; it does not include a minimum time requirement, so documentation of time is not required. The related higher level code, CPT 99239, has a minimum time requirement of 30 minutes or more, so time notation is a requirement for 99239. When 99239 is billed and documentation of time is not identified in the medical record the service may be reduced to 99238.
- Is an examination a required element for a discharge service (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.
- 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.
- What are the rules for billing pronouncement of death?
Answer: Pronouncement of death may be performed and billed by a physician, or a NPP member of the physician’s group who is acting on behalf of the physician. This service may be represented by an appropriate face-to-face hospital discharge code (CPT codes 99238 or 99239). Pronouncement of death by a resident or a nurse may not be billed to Medicare, since neither is a Medicare-enrolled provider.
- 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.
Reviewed 10/8/2024