Frequently Asked Questions

Billing Questions:
How do I bill a discharge day management code when I discharge my patient on day one, but dictate my notes on day 2? Which day do I use for submitting the claim?
o   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.
o   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.
o   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.
Under the Examination Section of the 1995 Guidelines, can we combine the body areas and organ systems?
o   No.  The examination section of the 1995 score sheet is divided into body areas and organ systems. The Current Procedural Terminology (CPT) manual recognizes 7 body areas and 12 organ systems. Depending on the documentation in the patient's medical record you can use either the body areas or the organ systems. An example could be: the documentation in the patient's medical record stated, abdomen soft, credit can only be given in the body areas under abdomen or in the organ systems under Gastro Intestinal (GI) which ever area benefited the physician the most.
Can a physician bill for an initial visit when a patient goes from observation to admission?
o   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:

How is medical necessity considered?

o   All services under Medicare must be reasonable and necessary as defined in Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section states, no payment may be made for any expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of injury or to improve the functioning of a malformed body member.  Therefore, medical necessity is the first consideration in reviewing all services.
o   Credit may be taken only if the physician includes the documentation from the previous visit.
o   ROS inquiries are questions concerning the system(s) directly related to the problem(s) identified in the HPI. Therefore, it is not considered "double dipping" to use the system(s) addressed in the HPI for ROS credit.
o   The number of possible diagnosis and/or the number of management options that must be considered is based on the number of types of problems addressed during the encounter, the complexity of establishing a diagnosis, and the management decisions that are made by the physician. Additional workup is defined as anything that is being done beyond that encounter at that time. i.e. If a physician sees a patient in his office and needs to send that patient on for further testing, that would be additional workup. The physician needs to obtain more information for his medical decision making.