preparation of discharge records, prescriptions and referral forms.instructions for continuing care to all relevant caregivers and.discussion of the hospital stay even if the time spent is not continuous.Hospital Discharge Day Management Services are used to report the total amount of time spent by the physician for final discharge of a patient.
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Physicians or qualified non-physician 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. Only the attending physician of record reports the discharge day management service.Only one hospital discharge day management service is payable per patient per hospital stay.The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified non-physician practitioner even if the patient is discharged from the facility on a different calendar date.Hospital Discharge Day Management Services are a face-to-face evaluation and management (E/M) service between the attending physician and the patient.Hospital Discharge Day Management Services All levels of subsequent care include a record review as well as a review of any diagnostic results and changes in the patient’s status since the last assessment by the physician.Two different physicians may bill concurrently for subsequent hospital care provided the physicians are from different specialties and are treating different diagnoses.Subsequent Hospital Care codes may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.These services require that two (2) of the three (3) “key” components, history, and/or examination and/or medical decision making, must be included in the medical record documentation in order to meet or exceed the criteria for the code.Modifier – AI would not be appended to these codes.
Physicians may report a subsequent hospital care code for services that were reported as CPT consultation codes (99251 – 99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay. Physicians must meet all the requirements of the initial hospital care codes, including “a detailed or comprehensive history” and “a detailed or comprehensive examination” to report CPT code 99221, which are greater than the requirements for consultation codes 9922.
Modifier – AI (Principal Physician of Record) should be appended to the initial visit submitted by the admitting provider.E&M services provided on the same date in a site other than the hospital that are related to the admission should not be reported separately but documentation by the admitting provider from other E&M services may be combined with the admission documentation to determine the appropriate level of initial hospital care. This code includes all services performed at all sites by the admitting physician that relate to the admission.Initial Hospital Care may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.All three (3) “key” components, history, examination and medical decision-making, must be included in the medical record documentation.Patient’s stay must be a minimum of eight hours in order to bill these codes. Hospital Discharge Day Management Services – E&M codes (99238, 99239) used to report the work performed to discharge a patient from an inpatient stay.Īdmission and Discharge Same Day – E&M codes (99234 – 99236) used to report services for a patient who is admitted and discharged from an observation or inpatient stay on the same calendar date. Subsequent inpatient care – E&M codes (99231, 99232, 99233) used to report subsequent hospital visits. Initial hospital care – E&M codes (99221, 99222, 99223) used to report the first hospital inpatient encounter between the patient and admitting physician.
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