Wiki Discharge....Time Spent


Maumee, OH
Best answers
Oops, I posted this in the wrong forum previously, let me see what I can get from here....

Hi all,
I recently attended an E&M presentation that WPS Medicare did and the speaker said a few things that caught me a tad off guard.

The presenter stated that on discharge days, the only requirement is time spent, I know that; however, she stated that if time is NOT documented a discharge cannot be billed?

Does this sound familiar to anyone and if so can you tell me where to locate this information?

I am not under WPS, however this is not how our MAC (Novitas - formerly Highmark) views this. If the doctor is billing a 99239, then the time over 30 minutes must be documented. If no time is documented, than the coder would be 99238. The discharge documentation must also include a description of the hospital course, a pertinent final exam and the discharge plan. They have never said that if the time is not documented than you can't bill - only that if it isn't the code would automatically be lowered to the 99238 in an audit.

I would try and have this statement from this presentation clarified by WPS!

Hope this helps! :)