Part B Insider (Multispecialty) Coding Alert

Published on Sun Jan 09, 2005 PDF

Use these 3 tips to improve your 99238 and 99239 reimbursement

Incorrectly using hospital discharge codes can cost you both time and money - up to $100 per claim. Here are the special rules and pitfalls you must learn to keep your discharge coding error-free.

Look For These 4 Events

There are four specific situations in which you may use CPT 99238 (Hospital discharge day management; 30 minutes or less) or 99239 (...more than 30 minutes).

1. Postoperative complications: If a physician readmits a non-Medicare patient for a postoperative complication such as a wound infection, and treats the condition without additional surgery, he/she may report discharge services. Remember, though, that Medicare does not pay for postoperative complications.

2. Trauma not requiring surgery: If a trauma patient is admitted to the hospital but did not require surgery (such as a burn victim), the physician may bill for discharge services.
 
3. Nonsurgical conditions: Physicians may report discharge services for a patient who is admitted for treatment of a nonsurgical condition, such as dialysis.

4. Patient is no longer in the global period: For example, if a surgeon performed a tracheostomy for airway blockage (which has zero global days) and the patient is discharged three days later, you may bill for discharge services.

Remember: You may NOT bill for discharge services if the patient has had surgery and the procedure has a global period.

Time is of the Essence

Codes 99238 and 99239 are unusual because they are based on the amount of time the physician spends discharging the patient rather than the level of service provided. And, unlike time measurements in the office, which bases time only on patient face-to-face time, the time used for 99238 and 99239 is based on floor time..

Many people are confused by these codes because they don't understand what constitutes "hospital discharge day management" says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania's hospital in Philadelphia. CPT states that the codes cover, "as appropriate," a physical examination of the patient, discussion of the hospital stay, time spent giving instructions to relevant caregivers and preparation of discharge records, Pohlig notes.

But not all of those services are required for discharge management, explains Pohlig: The physician must only provide the services he/she believes are appropriate. Sometimes the physician may delegate part of the discharge service, such as giving instructions to a caregiver, to other staff members.

Try These 3 Tips

Follow these three tips to improve your earnings when coding discharge services:

1. Find out if the carrier requires a face-to-face for discharge services. Medicare does not state that the physician must examine the patient to bill discharge codes, but they are E/M codes, and "most E/M services require a face-to-face," says Pohlig. However, the idea is that inpatient hospital care is all floor time, comments Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions, Inc. in Brick, NJ.

The CPT code does not state the physician must have face-to face time with the patient; 99221 reads "Physicians typically spend 30 minutes at the bedside and on the patient's hospital or floor unit." "Writing prescriptions and talking to caregivers is not face-to face," Cobuzzi points out.

2. Document the total time spent discharging the patient. The time spent is cumulative, so if the physician spends from 9:00 a.m. to 9:10 a.m. with the patient and then spends from 9:30 a.m. to 10:00 a.m. on the floor writing orders and coordinating care, the total time spent is 40 minutes, and you should bill 99239.

You cannot report 99239 unless the physician spends more than 30 minutes discharging the patient and clearly documents what he or she did during that time; be it an exam, writing orders or talking to caregivers. For example, the physician's note could read, "spent 10 minutes talking to patient" and "spent 30 minutes writing instructions and discharge summary." If the time is not clearly documented, the insurance carrier may default the code to 99238.

The documentation needs to substantiate the amount of time reported by the physician, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management in Spring Lake, N.J. "Physicians can't just say, 'Patient was given discharge instructions'- they need to give a brief synopsis of what they did." This is especially important if you are using 99239, says Brink.

3. Take care when coding discharge services provided by two physicians. If Physician A discharges the patient and Physician B writes the discharge summary, you would bill 99238-99239 under Physician A, which is the physician who did the work, says Lisa Center, CPC, quality coordinator with Freeman Health System in Joplin, MO.

Also be aware that unless the admitting physician has transferred care over to another physician, only the admitting physician may bill discharge codes, warns Pohlig. If your physician is just one of the specialists involved in the care, he/she may not bill discharge codes.

Don't Overlook: Practices may bill discharge codes if the patient has died, because the physician must fill out the record of death and discharge the patient to the funeral home, says Pohlig.

You may also bill discharge codes if the patient is admitted to a nursing home on the same day (specifically a skilled nursing facility) she is discharged from the hospital. This is the only situation in which you may bill both discharge and admit codes on the same day, says Cobuzzi.

Steer Clear of These Scenarios

There are a number of situations that may look discharge code-friendly, but they're not. Do not use discharge codes in any of the following situations, cautions Center: