Documentation of Discharge Day Management- Part 1

Discharge Day ManagementThere's a bunch of work that's included when it comes to documenting discharge day, which includes any kind of review of records. Suppose they were doing this over the internet via email, if they had access to an EMR and gave them the password to take a look at the records, anything that was looked at, viewed, imaged any review of medications, any review of any pertinent pathology information that had to be there, all of those would have to be reviewed. But the consulting physician does not report an interpretation of any of these studies, is having done them separately, all he's doing now is reviewing the results so that he can give an opinion about what needs to be done for this patient because he cannot come down and see her.


What needs to be documented in the records is either a written or a verbal request by the treating physician or the qualified non-physician practitioner who requested this consultation. But it has to be documented in the patient’s record. For instance, Marcus Welby says, “I had to call in Dr. Ob-Gyn for this particular case.” And he's documented this in the patient’s file, “Contacted Dr. Ob-Gyn at 10:00 pm via telephone and advised the patient’s status, reviewed, dada dada,” that kind of stuff. But he doesn’t need to go into as much detail as the consultant would.

He has to document in the record the reason for the request. And then there has to be some real time communication going on here. It has to be – it can be online or on the phone. But it's not asking a question of someone and then waiting for 50 minutes for a reply via email. This has to be real time. So the two of them are sitting at the keyboard typing, having that conversation or on the phone having that conversation. And then finally, there must be a written report from the consultative physician back to the treating physician saying what his or her opinion had been and what he advised, and that kind of thing. Just like any other consult, you have a request, you have the review and now you have the written report that goes back into the patient’s medical chart.


So when don’t you report the code? If it's an immediate transfer of care to the consultant, then you wouldn't report this code. If there was some face-to-face service within the next 14 days or the next available appointment date by the physician who's asked for his opinion or advice, you wouldn't report this code. If the patient has been seen by the consultant within the last 14 days prior to the consult, you would not report this code. And if that internet or telephone consultation was less than five minutes, you would not report the codes. And if the only reason for the communication between these two was to transfer care of the patient to the consulting physician, you would not report these codes.


If there was a big geographical distance between the treating physician and the consulting physician where it's very unlikely that the consultant will get to see the patient immediately or had seen them, you know, just a few days ago. The treating physician actually gets to report something as well. And this is because that face-to-face – not non-face to face encounter with the consultant has actually added the time to the care the physician has rendered. Now, we know under most E/M codes, there's pre and post-time included. And generally speaking, follow-up calls to the patient would be included as part of all of that work.


But in this case, we've always said that coordination of care had to be with the patient present. Well, in the case of these new consultative codes, obviously, the consultant and the coordination of care, that person’s not present, the patient may or may not be in the room when this is going on.

And so, the physician who's asked for the opinion or report - opinion or advice, may in fact be able to bill prolonged services codes either in a face-to-face setting or a non-face to face setting. But as we all know, you have to exceed the typical time of the E/M code that is being billed by the treating physician by at least 30 minutes.

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