Coding corner

Advice on discharge billing, and whether critical care codes depend on location.


Q: Can I bill a patient for a hospital discharge and a nursing facility admission on the same day?

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A: Yes. Although in most cases only a single evaluation and management (E/M) service may be reported by an individual physician for the same day, there is an exception in the case of a hospital discharge (99238–99239) and nursing facility admission (99304–99306). A physician who performs both these services will be paid for both by Medicare without the use of a modifier on either code.

In addition, a physician may bill for an office-based E/M service on the same day as a hospital discharge, but such a situation would be somewhat unusual and would have to be medically necessary.

Q: Can more than one physician report a hospital discharge?

A: No, only one physician may report a hospital discharge management code (99238–99239) on a given day. If two physicians in the same specialty from the same group provide services on the last day of a hospital stay, the time of those physicians should be considered together when determining which hospital discharge code to use. 99238 is used for discharges that require less than 30 minutes of physician time, and 99239 is used for discharges that require more than 30 minutes of physician time. As is the case for all time-based services, physicians should document the amount of time spent on this service in the medical record.

Q: Can I code for critical care services if my patient is outside of a critical care unit?

A: Yes. The critical care codes (99291–99292) have nothing to do with the location of a patient in a critical care or intensive care unit, although patients in those units may be most likely to receive the services. In order to bill for critical care services, the physician must meet the requirements of the CPT codes, which include “high complexity decision making to assess, manipulate, and support vital organ systems….and prevent further life-threatening deterioration of the patient's condition.” If a physician provides these services to a patient, he or she may report critical care, whether the patient is in an ICU, on a standard medical floor, or even in an outpatient office. Critical care services should not be routinely reported just because a patient is in an ICU.

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Critical care services are time-based services, so it is important to document the amount of time that was spent by the physician. Critical care services of less than 30 minutes are not separately reportable.