When discharging a patient from a nursing home, there are two CPT codes that are used for billing. CPT code 99315 should be used for visits lasting less than thirty minutes, while CPT code 99316 would be used for any visit greater than thirty minutes.
There is more to discharging a patient from a nursing home than doing a quick progress note and billing insurance. It is critical for the health of the patient that you arrange for a safe discharge to the community.
Discharging patients require spending the time to make sure the patient is safe to leave the nursing home, have the necessary medications and DME equipment, and have support services at home.
Identifying patients who are going home to the community
Patients are identified by the social workers, nursing supervisors, and physical therapy for discharge to home. Once they feel that they are safe for discharge, social workers often consult with staff nurses to identify any further issues that may prevent the discharge.
Patients are discharged to the community from skilled nursing homes due to:
- Improvement in the health of the patient.
- Health insurance no longer covers stay at a nursing home.
- The patient can have further physical therapy, occupation therapy, and nursing support in the home.
- The patient is stating they want to go home even if they would benefit from a longer stay at the skilled nursing home. They have shown improvement enough to be safe.
- The resident insists on leaving against medical advise (AMA), even though they may not be stable at home.
Once the facility identifies candidates for discharge, the staff will relay the discharge message to the medical provider. The medical provider is often the nurse practitioner in the facility. However, some doctors prefer being the ones to discharge the patient.
Once the medical provider is informed about the patient going home, they will need to evaluate the patient.
Evaluation of the patient for discharge from nursing home
The discharge evaluation is based on time and utilizes CPT codes 99315 and 99316. Since you are determining your visit based on time, you need to keep track of the total time spent with the patient’s discharge.
Total time includes everything from start to finish, including evaluation of the patient and writing the discharge orders.
Steps required to discharge a patient from nursing home include:
- Document the start time of when you begin the process of discharging the patient.
- Discuss the plan of care for the patient with the social worker, nursing supervisor, and unit nurse.
- Review the patient’s medical chart.
- Determine if there any red flags that may prevent the patient from going home?
- Does the resident need any durable medical equipment (DME) that will be needed for the patient to go home and perform daily activities of living?
- Ask the nurse to let you know which medications the patient will need for discharge home.
- Begin the evaluation of your patient.
- Ask resident;
- What pharmacy do you use?
- Who is your primary care provider in the community?
- Will they have assistance at home?
- Do they have the ability to get in and out of their home (stairs, wheelchair ramp, etc.)
- Do they feel they will be able to provide self-care?
- Any other agencies involved after they discharge to home?
- Do they have any pain and whether their opiate pain meds can be decreased before discharging home.
- Will they have specialist appointments after discharge and do they know when they are scheduled. Some providers will send a copy of their progress notes to the PCP and specialists in the community.
- Perform the physical exam on the patient.
- You may need to call family or caregivers to coordinate the discharge. Often they will need to provide care for the patient in the home.
- Write the order to “discharge the patient to home with medications, supplies, and support.”
- Ask the nurse what medications the patient will need for discharge.
- Complete your documentation of your discharge note.
Nursing home discharge Against Medical Advise (AMA)
Sometimes there are situations where the patient or family demands to be discharged from the nursing facility before they are ready or cleared to leave. In these situations, education and proper documentation are important to protect the patient, facility, and provider.
When approached by the facility to evaluate a patient requesting to leave AMA, you should try to do a medical evaluation before they leave the facility.
Identify any psych or medical issues that may prevent them from leaving against medical advice. If the patient is not of the right mind then you will need to get clearance before discharging them home. If there isn’t a psych provider available they may need to be sent to the Emergency room for clearance before leaving.
If the patient is considered stable, you may decide to discharge against medical advice with a short supply of medications to cover until their next PCP appointment. However, most providers do not prescribe any medications, and the facilities do not send them home with medications.
The liability of treating and evaluating patients that leave AMA and have an adverse event is beyond the scope of this article. However, there are ways to lessen the potential for harm.
Make sure to document education regarding your recommendation to stay longer at the nursing home for rehab. If stated, document their verbalization and understanding of your reasons and education.
Make a recommendation for the resident to follow up with a primary care provider (PCP) in the community as soon as possible.
If you are unable to convince your patient to stay, the facility will attempt to have the patient sign paperwork before leaving AMA.
Document your progress note like any other note, and you can bill for the visit due to the medical complexity and your attempt to avoid harm to the patient.
Can a nurse practitioner discharge a patient from a nursing home?
APRN’s can discharge patients from nursing homes. They can write the order for discharge, review meds, and coordinate care for the safe discharge of the patient.
However, Medicare currently doesn’t allow the nursing practitioner to order visiting nursing services which most patients being discharged from the nursing home require. Medicare rules about VNA orders doesn’t mean you cannot discharge the patient, but the patient will need to see their PCP in the community within one to two weeks after discharge.
Some attending physicians prefer to discharge their patients from the nursing home. They may also want an update from the APRN or PA evaluating the patient for discharge before an order is given.
How we recommend completing a discharge progress note
- Chief Complaint (CP) will usually be the reason for the visit. In this case, it is a discharge evaluation.
- History of Present Illness (HPI): Include the reason for the visit and what was the original reason for admission to the facility. Give a basic explanation of what occurred to bring them to the nursing home for rehabilitation.
You should document a basic course of treatment for the resident along with any major complications that may have occurred.
Include pertinent comorbidities that may be related to the original visit that would contribute to them failing in being discharged to home.
Did the patient develop any complications during their stay and was it resolved or ongoing?
Follow protocols for completing an HPI when completing your note.
- Review of systems (ROS): Document a thorough review of what the patient is feeling and verbalizing during your visit. You want to make sure that the patient is stable for discharge.
The ROS is an opportunity to discuss issues or concerns that the patient may feel will prevent them from being readmitted to a nursing home or emergency room after discharge. It will help if they can feel they will be successful in their transition home, so give them time to talk and ask questions.
- Current diagnosis list for the patient.
- Physical Exam: Perform a comprehensive examination when possible to allow for documentation of the current condition of the patient before discharge.
- Laboratory and Studies: include studies that help show the resolution or stability of the patient upon discharge.
- Assessment and Plan: Include diagnosis (ICD 10 code) for the visit that originally brought them to the facility. You want to document resolution and stability regarding these diagnoses and what is the plan after discharge to home.
- Document medications the patient may take at home, plan of care, followup with PCP and specialists, and other instructions that the patient may require.
- Document the time for the evaluation visit. Did the discharge process take greater than or less than thirty minutes to complete?
- If you are a nurse practitioner or physician assistant, you should document any collaborations you may have had with the attending physician or other specialists.
- The final two steps in the discharge process will be to determine if the visit is 99315 or 99316, then you will sign your note.
Things to document in your note
- “Followup with PCP within 1 to 2 weeks post-discharge along with any specialists that are involved with care.”
- “Discussed the risks/benefits of patient’s meds. Reviewed need for prescriptions.”
- “Discharge information given to the patient regarding chronic disease/problem list and reviewed and updated where indicated.”
- “Discussed diagnoses and plan, including risks and options of treatment.”
- “Greater than 30 minutes spent with coordinating discharge of patient. Including management and evaluation of the patient for safe discharge” (only if this is true).
- “Orders in the chart to discharge the patient home with services and supplies.”
- “The patient was educated to call PCP should the patient experience fevers, chills, nausea, vomiting, shortness of breath, pain or other concerning symptoms.”
- “Patient is hemodynamically stable for discharge from the facility.”
Medications needed for Discharge
Insurances have different rules regarding sending home facility medications. Some states mandate that leftover medications be sent home with the patient. Medicare allows the facility to keep the medications to turn in to the pharmacy for rebate.
Either way, the nurse will let you know which medications require a refill. You can send in the order via:
- Electronic Prescription via EHR.
- Call medications into the pharmacy.
- Provide handwritten scripts to the patient or families.
It is up to the provider to determine the quantity of the scripts. Most providers write two weeks to thirty-day supplies. Some providers will only write an amount to cover the patient until their next scheduled primary care appointment in the community.
We recommend the patients receive a maximum of two-week supply of opiates and benzodiazepine medications. They will need either a primary care appointment, mental health practitioner, or pain management specialist scheduled before leaving home if on these medications.
Durable medical equipment (DME)
Your note will need to document the reason the patient will require certain DME equipment for discharge such as wheelchairs, hospital beds, Hoyer lifts, etc.
Most DME equipment suppliers will provide you with forms showing what they need to see in the documentation to get the equipment covered for Medicare.
Documentation for DME Equipment examples
- “The patient presents with significant limitations in gross motor and functional mobility skills from lower/upper extremity muscular weakness.”
- “Impaired motor control”
- “The patient will benefit from having a wheelchair/hospital bed/Hoyer due to a decrease in activity tolerance and mobility limitation that cannot be sufficiently resolved by use of an alternative aid (i.e. cane, walker, regular bed). “
- “The patient has a mobility limitation that significantly impairs his/her ability to participate in mobility-related activities.”
- “It would be medically appropriate and necessary for safety and to improve the patient’s ability to participate in all mobility-related activities.”
Conclusion
The discharge process can determine if the patient will be successful when they are discharged home. By following consistent steps with a medical discharge, you will make sure that everything is done to ensure a safe discharge to home.
Discharging a patient’s home is the medical provider’s opportunity to provide excellent customer service, possibly resulting in the patient wanting to return to the nursing home in the future.
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