Discharge Note on a Patient I Never Saw?

November 19, 2010

This physician wonders why he has to dictate an H&P and discharge summary for a patient he never actually visited.

Question: A patient was discharged from the hospital after a weeklong stay. She then returned the next day, very sick, and I admitted her to my service. She was seen by two specialists in the ICU before I saw her. She coded and died that same day. She is a Medicare patient. The hospital says I have to dictate an H&P and discharge summary - on a patient that I never saw. Do I have to do the dictations, and can I bill something for it?

Answer: All the inpatient E&M codes require that you see the patient or perform work on the patient’s floor. Medicare has always been particular in that to qualify as an encounter there needs to be a face-to-face visit. In the office, counseling must be face to face with the patient even though the CPT manual says with “patient and/or family.”

CPT definitions of inpatient coordination of care do not specify that a bedside visit is required, but as above, Medicare seems to require it. There really isn’t a code on the Medicare fee schedule that captures this work.

If the patient had lived, and, say, was off the floor getting tests when you came to see her, you could have summarized the history and the decision-making and billed a follow-up visit or discharge code based on time spent coordinating care. Even this is on the assertive side of coding - but there is work, you were there, and the time would be recorded. It may be denied, but it isn’t fraud.

But because the patient died, the payer could argue that any work done was for the hospital’s record-keeping benefit - and had no benefit to the patient - and was not “medically” necessary. They could even state that since this was post-mortem, there was no longer a beneficiary to be billed. You’re caught between a rock and a hard place.

You have to dictate the note because likely hospital bylaws require it. In my opinion you can’t bill in this scenario. I think this comes under the heading of the down side of the “you win some, you lose some” concept.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or physicianspractice@cmpmedica.com.

This question originally appeared in the March 2010 issue of Physicians Practice.