Wiki Discharge Services

jdibble

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I just started auditing the Hospitalists charges for our hospital and I need some guidance. Since Discharge services are time based, does the documentation that the doc does have to state somewhere the total time spent on the discharge? Wouldn't that be needed to code? None of these docs have documented time in there reports but have chosen the 99239 over the 99238.

Any help would be great!

Jodi Dibble, CPC
 
99239

In order to code 99239 Hospital Discharge Day Management, more than 30 minutes - the documentation MUST include time of 31 minutes or longer.

If no time is listed the most you can code is 99238.

F Tessa Bartels, CPC, CEMC
 
Tessa,
I have looked specifically for that in writing by my local carrier and CMS. No where is that documented. In the CPT book it does not state that it "must" include time, like it does about critical care coding. Yes it is implied but I need to be able to show this in black and white. Do you have it?
 
link

CPT guideline:

The hospital discharge day management coders are to be used to report total duration of time spent by a physician for the final hospital discharge of pt.

So like any other code that has time we are required to state it in the documentation. The webinar link above will take you to a webinar that has a good example.
 
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