General Surgery Coding Alert

For example, the surgeon admits a non-Medicare patient for treatment of postoperative complications. Upon discharge, the surgeon reports 99238. In this case the surgeon would have to append modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the discharge code to describe the service as not included in the global surgical package of the prior surgery.

You should report 99238 and 99239 for "all services provided to a patient on the date of discharge, if other than the initial date of inpatient status," according to CPT. These codes are time-based, and you should report 99239 only if the surgeon spends more than 30 minutes performing discharge services.

A. Don't Forego Face-to-Face Meetings

The Question: What should you do if the surgeon gives a discharge order for a patient, then talks to the nurses and dictates the summary but does not conduct a patient exam before the patient leaves the hospital?

The Facts: CPT does not directly state that face-to-face encounters are necessary during discharge (leaving it to physicians to determine whether such encounters are appropriate), but the guidelines imply that physicians should meet with patients during the discharge process.

Face-to-face contact with patients is inherent in all CPT E/M codes, including discharge summaries. Therefore, most coding consultants suggest you be sure that the surgeon documents that he was physically in the room with the patient.

Indeed, the whole issue of face-to-face encounters with physicians during discharges is controversial, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J.

Protect Yourself: Consult your carrier if you're not sure about face-to-face exam requirements, Brink says. Some payers publish specific guidelines that address this topic. HGSAdministrators, a Pennsylvania Part B carrier, printed the following in its E/M Documentation Guideline FAQs:

"When a patient is discharged prior to the daily visit by the physician, a discharge day management service can be billed to Medicare if the medical record includes documentation of a service rendered, e.g., instructions for continuing care to all relevant caregivers and preparation of discharge records, prescriptions and referral forms."

The insurer states, however, that it "would expect to see that this is rare," and that the majority of the discharged patients should be "seen face-to-face by the physician for a final examination."

B. Count Total Time for 99238 and 99239

What you MUST do: Because hospital discharge codes are time-based, the surgeon must document the total time that he spends with the patient during discharge.

How you can improve: The physician should record start and stop times, Brink says. Including start and stop times shows that you're conscious of time requirements, whereas documenting total minutes is less accurate.

If you plan to document the total time the physician spent, rather than recording time increments, you should make sure you have enough documentation to demonstrate that the physician provided the discharge services.

If, for instance, the surgeon states that he spent 20 total minutes providing all services -- including examining the patient, giving instructions on exercise and completing records -- his discharge notes should detail all services that he provided in that 20-minute period.

And, if the physician reports 99239, the discharge report should include direct statements such as, "I started the discharge service at 9:00 a.m. and finished at 9:50 a.m." or "I spent a total of 50 minutes providing discharge planning and other services."

The bottom line: Physicians should never use 99239 unless they spend more than 30 minutes in discharge planning and document what they did, says Charol Spaulding, CCS-P, CPC, CPC-H, vice president of Coding Continuum Inc. in Tucson, Ariz. "If they do not document time, you should default to 99238," she says.

C. Don't Report Discharges for Same-Day Admits

What NOT to do: You should not report the hospital discharge codes 99238-99239 if you admit and discharge a patient on the same date. "For a patient admitted and discharged from observation or inpatient status on the same date, codes 99234-99236 should be reported as appropriate," according to the March 1998 CPT Assistant (this information is still current).

If you discharge an inpatient but admit her to a nursing facility on the same date, you can report both the hospital discharge (99238-99239) and the nursing facility admission code (99303), according to CPT.