A complex process, discharging patients from the hospital comes with many challenges, including liability risks. Nurse-led discharge, however, has gained wide acceptance in many developed countries as it has the potential to ensure that the patient receives the same quality medical care in order to prevent readmission. But is nurse-led discharge always legitimate or are there situations when a nurse practitioner cannot discharge a patient? An article published in Medscape points out that the answer to this question depends on:
- Differentiating between three services: writing the discharge order, performing the discharge service, and writing the discharge summary.
- Whether the nurse practitioner and physician work for the same hospital or not.
- Liability risks.
The discharge order is entered in the patient’s medical record and informs nurses and other staff that the attending physician has permitted the patient’s release.
Performed by the clinician, the discharge service covers the final examination of the patient, discussion about hospital stay, instructions for continuing care, and preparation of the discharge records, prescriptions, and referrals. CPT code 99238 or 99239 is used to bill Medicare’s for a Hospital Discharge Day Management Service, which is a face-to-face evaluation and management (E/M) service between the attending physician and the patient. Payment is based on the time spent on providing the service.
The discharge service includes writing the discharge summary, which informs future providers about the patient’s stay, post-discharge plans, and matters pertinent to future care. Hospitals require written discharge summaries to document proof of services provided for medical billing purposes.
Medicare rules for the discharge service specify the role of the attending physician and the nurse practitioner:
- While a nurse practitioner may perform physician services for a hospitalized patient, federal law requires a physician (or a physician acting on behalf of the attending physician) to be the attending physician of record.
- Only the attending physician or physician acting on behalf of the attending physician) shall report the Hospital Discharge Day Management Service using CPT codes.
- The attending physician should write the discharge order and discharge summary.
- Claims fordischarge service should be supported with documentation that the clinician performed the essentials of the service.
In this case, the nurse practitioner can perform the discharge service on behalf of the attending physician if both of them are on the hospitalist team. The hospital will bill the service. However, this rule does not apply in the following situations:
- If the nurse practitioner is employed by the hospital and a private physician who is not an employee of the hospital attends the record, this private physician, or his or her employed nurse practitioner or physician assistant, should perform the discharge service.
- If a surgeon is the attending provider, reimbursement for the discharge service comes under the global fee, and the surgeon is responsible this service and gets paid for it.
- If the attending provider is a cardiologist, and the patient stays overnight in the hospital after the treatment, the cardiologist should perform and bill the discharge service.
The bottom line: If a hospital-employed nurse practitioner performs the discharge service, it is against the law for private physician to bill for it. If the attending physician and the nurse practitioner do not have the same employer, Medicare’s shared E/M visit rules do not apply.
Professional medical billing and coding companies are knowledgeable about billing for transitional care and discharge services. They can ensure that these services are billed using accurate codes and that claims are supported with proper documentation. Knowing the rules matters a lot when it comes to getting proper reimbursement and avoiding malpractice risks.
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