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How to bill Initial Hospital Care and Discharge on Same Day
When the patient is admitted to inpatient hospital care for less than 8 hours on the same date, then Initial Hospital Care, from CPT code range 99221 – 99223, shall be reported by the physician. The Hospital Discharge Day Management service, CPT codes 99238 or 99239, shall not be reported for this scenario.
When a patient is admitted to inpatient initial hospital care and then discharged on a different calendar date, the physician shall report an Initial Hospital Care from CPT code range 99221 – 99223 and a Hospital Discharge Day Management service, CPT code 99238 or 99239.
When a patient has been admitted to inpatient hospital care for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date, Observation or Inpatient Hospital Care Services (Including Admission and Discharge Services), from CPT code range 99234 – 99236, shall be reported.
D. Documentation Requirements for Billing Observation or Inpatient Care Services (Including Admission and Discharge Services)
The physician shall satisfy the E/M documentation guidelines for admission to and discharge from inpatient observation or hospital care. In addition to meeting the documentation requirements for history, examination and medical decision making documentation in the medical record shall include:
• Documentation stating the stay for hospital treatment or observation care status involves 8 hours but less than 24 hours;
• Documentation identifying the billing physician was present and personally performed the services; and
• Documentation identifying the admission and discharge notes were written by the billing physician.
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