Time of death in a hospital

[TTcpc]

Could someone help me with what the documentation requirements are for a physician who is pronouncing a patient dead in the hospital inpatient setting? I have a physican who is wanting to bill a 239 when all the documentation in the chart from the nurse is that she found the body and the physician, unit manager, and family were notified. The only physician documentation is that patient "found dead and pronounced". The physician responded to the biller via email that she was actually on the unit and the nurse got the physician who went in and pronounced the patient and the physican called the family.

I am trying to find documentation regarding whether this is sufficient to use or if the physician must document more such as examined body, no pulse, no respirations, patient pronounced dead at 12:01 p.m. or something like that.

Thanks!!!

 

[jvanek82]

According to CPT, to bill a 99239 the doctor must document that they spent over 30 minutes in discharging the patient. This would include examining the pt, discussion of the stay, instructions for continuing care to any caregivers and prep of discharge records, rx and referrals - which must be documented. Would this doctor have spent that much time in pronouncing this patient? If the time is not documented, then the code would be 99238.