CurrentFlorida BluePolicy 21-075

Hospital Inpatient or Observation Discharge Policy

Defines reporting and payment expectations for hospital inpatient or observation discharge E/M services (including admission/discharge same-day services) for Florida Blue members and providers across all lines of business.

Policy Summary

PayerFlorida Blue

PolicyHospital Inpatient or Observation Discharge Policy

Policy CodePolicy 21-075

Change TypeNo material change

Effective DateSep 16, 2021

Next Review Date

Key ActionReport only one discharge day management service per patient per hospital stay; if multiple claims received, the first claim is allowed and subsequent claims will be denied unless appropriate, in which case recovery and rebill will be initiated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99234-99236, 99238-99239CPT® codes described

Only onePayable per stay

45/70/85 minTime thresholds (99234/35/36)

30 minDischarge threshold (99238 vs 99239)

All linesApplicability

Policy Summary

PayerFlorida Blue

PolicyHospital Inpatient or Observation Discharge Policy

Policy CodePolicy 21-075

Change TypeNo material change

Effective DateSep 16, 2021

Next Review Date

SourceLink

On This Page

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Coverage criteria

Covered when ALL of the following are met:

ALL of the following

A
- Use CPT® 99234-99236 when the patient is admitted and discharged on the same calendar date and the same physician or physician team performs both the initial and discharge services.
- When reporting 99234-99236 for observation or inpatient care, the patient’s stay must be at least 8 hours but less than 24 hours when applicable.
B
- Select the level 99234 when history/exam and Medical Decision Making (MDM) meet criteria for straightforward or low MDM, or when total time on the date of encounter is at least 45 minutes.
- Select the level 99235 when history/exam and MDM meet criteria for moderate MDM, or when total time on the date of encounter is at least 70 minutes.
- Select the level 99236 when history/exam and MDM meet criteria for high MDM, or when total time on the date of encounter is at least 85 minutes.
Report CPT® 99238 or 99239 for face-to-face discharge day management performed by the physician (or other qualified health care professional) responsible for the patient’s discharge; differentiate by total time on the date of encounter (99238 = 30 minutes or less; 99239 = more than 30 minutes).
Only the attending physician of record may report the discharge day management service; other physicians should report Subsequent Hospital Care (CPT® 99231-99233) if appropriate.
Only one hospital discharge day management service is payable per patient per hospital stay. If multiple claims with a discharge day management code are received, the first claim will be allowed and subsequent claim(s) denied with instruction to rebill with the appropriate code; if a subsequent claim is determined to be the correct claim, recovery and rebilling will be initiated.
The discharge day management visit is reported for the date of the actual visit even if the patient’s discharge from the facility occurs on a different calendar date.
Services and payment are subject to the member’s benefit plan document, medical necessity review where applicable, and provider contract; this policy applies to services reported on a CMS-1500 form or electronic equivalent and to all lines of business.

Applicable CPT Codes and Time-Based Guidance

Hospital inpatient/observation admission & discharge and discharge-only codesCPTCovered

99234	Hospital Inpatient or Observation care, for the evaluation and management of a patient including admission and discharge on the same date which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
99235	Hospital Inpatient or Observation care, for the evaluation and management of a patient including admission and discharge on the same date which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 70 minutes must be met or exceeded.
99236	Hospital Inpatient or Observation care, for the evaluation and management of a patient including admission and discharge on the same date which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded.
99238	Hospital discharge day management; 30 minutes or less on the date of the encounter.
99239	Hospital discharge day management; more than 30 minutes on the date of the encounter.

Time thresholds for code selection when using total time

99234When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.

99235When using total time on the date of the encounter for code selection, 70 minutes must be met or exceeded.

99236When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded.

99238Hospital discharge day management: 30 minutes or less on the date of the encounter.

99239Hospital discharge day management: more than 30 minutes on the date of the encounter.

Claim Submission, Billing Rules, and Duplicate Handling

Billing Rule

Submit only one discharge day management service per stay; duplicate claims handled by first-claim rule

Only one hospital discharge day management service is payable per patient per hospital stay. When multiple claims are received that include a discharge day management CPT code, the first claim received will be allowed and subsequent claim(s) will be denied with instructions to rebill with the appropriate subsequent hospital care code. If it is later determined that a subsequent claim was the proper claim for the discharge service, recovery of the first submission will be initiated and the provider will be asked to rebill appropriately.

Report only one discharge day management service per patient per hospital stay.
If multiple claims received, the first claim is allowed; subsequent claims denied with instruction to rebill with an appropriate subsequent hospital care code (e.g., 99231-99233).
If a subsequent claim is determined to be the correct claim for the discharge service, recovery of the first submission will be initiated and rebilling will be requested.

Service Definitions and Same-Day Admission/Discharge Criteria

Final hospital or observation discharge E/M service (CPT® 99238, 99239)

Included componentsFinal examination, discussion of the hospital stay, instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions, and referral forms.

Who may reportThe physician or other qualified health care professional responsible for the final hospital or observation discharge reports 99238 or 99239.

Time basis for code selectionCodes 99238 and 99239 report the total duration of physician or qualified health care professional time on the date of discharge, even if not continuous.

Use of codes 99234-99236 for same‑day admission and discharge

When to use 99234-99236Use these codes when a patient is admitted and discharged on the same calendar date and the same physician or qualified health care professional team performs both the initial and discharge services.

Minimum duration requirementPatient receives observation care or is admitted to inpatient hospital care for a minimum of 8 hours but less than 24 hours on the same calendar date.

Level selectionSelect 99234, 99235, or 99236 based on medically appropriate history/examination and the level of Medical Decision Making (MDM) or by meeting the total time thresholds (45/70/85 minutes respectively).

OpenPayer

Hospital Inpatient or Observation Discharge Policy

Coverage and Reporting Requirements

Applicable CPT Codes and Time-Based Guidance

Claim Submission, Billing Rules, and Duplicate Handling

Service Definitions and Same-Day Admission/Discharge Criteria