Highmark Medicare Advantage Medical Policy in West Virginia
Section: CMS National Guidelines
Number: N-164
Topic: Subsequent Hospital Visits and Hospital Discharge Day Management Services (See Reference Section)
Effective Date: April 13, 2009
Issued Date: April 13, 2009

General Policy

This policy outlines the general billing of subsequent hospital visits and hospital discharge day management services.

Indications and Limitations of Coverage

Subsequent Hospital Visits During the Global Surgery Period 
Payment for surgical procedures includes all the services and visits (e.g., evaluation and management visits) that are part of the global surgery payment including when such surgical procedures may be fragmented.

Subsequent Hospital Care visits (codes 99231-99233) are not separately payable when included in the global surgery payment.

Hospital Discharge Day Management Service
Hospital Discharge Day Management Services, code 99238 or 99239 is a face-to-face evaluation and management (E/M) service between the attending physician and the patient. 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. Only one hospital discharge day management service is payable per patient per hospital stay.

Only the attending physician of record reports the discharge day management service. 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 (code range 99231-99233) for a final visit.

Payment for general paperwork is included through the pre-and post-service work of evaluation and management (E/M) services.

Subsequent Hospital Visit and Discharge Management on Same Day 
Payment will only be made for the hospital discharge management code on the day of discharge unless it is also the day of admission.

Physicians shall use the Observation or Inpatient Care Services (Including Admission and Discharge Services) using a code from code range 99234-99236 for a hospital admission and discharge occurring on the same calendar date and when the following criteria is met:

A subsequent hospital visit in addition to a hospital discharge day management service reported for the same date of service by the same physician is not eligible for reimbursement.

Hospital Discharge Management and Death Pronouncement 
Only the physician who personally performs the pronouncement of death shall bill for the face-to-face Hospital Discharge Day Management Service, code 99238 or 99239. The date of the pronouncement shall reflect the calendar date of service on the day it was performed even if the paperwork is delayed to a subsequent date.

Procedure Codes

992319923299233992349923599236
9923899239    

Coding Guidelines

Publications

References

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Online Manual Pub. 100-4, Chapter 12, Sections 30.6.9.1 and 30.6.9.2

Transmittal 1460, CR 5794

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.