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what would you do with this discharge?

renifejn

Guru
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99238 or 239?


Note is written for the day, but before the plan is this:

"We again spent 30 to 40 minutes on reviewing asthma pathogensis, guideline based care, the need for inhaled steroids, and prognosis. We reviewed that even though she would be started at a high dose of inhaled steriods, we would think that after a period of good control this could be stopped down working with her allergist.

Plans:
1. continue albuterol q4h for next 48 hrs
2.
3
7. etc.


Would you give this a 99239 since it's over 30 min?
 
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Milwaukee WI
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Muddying the waters

Your documentation states:
"We again spent 30 to 40 minutes ..."

First, "30 to 40 minutes" does not tell me that it was definitely over 30 minutes. Sounds like the physician is guessing as how long a time was spent. Could be only 30 minutes, which would be 99238.

On the other hand, s/he also writes "again spent" ... which might mean that there was a different session with the patient going over these issues, over and above the basic service, which would tend to make me think the total work involved was truly over 30 minutes. But I don't know this physician, so am not familiar with the usual way s/he dictates.

I'd educate the physician on the time requirements for this code so s/he could be more clear in the future.

To answer your basic question, I'd code this 99238 unless the physician could clearly demonstrate that the time spent was over 30 minutes.

F Tessa Bartels, CPC, CPC-E/M
 

kmaher

Networker
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Saginaw, MI
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I agree! The Dr. doesn't clearly state the total time spent with the patient just a time frame. I would take the documentation back to my physician and try to find out if it was closer to 30 minutes or 40 minutes, then after this is properly documented, I would then choose my CPT code. But I agree the physician needs to be educated on the importance of accurate time documentation.
 

renifejn

Guru
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208
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Another time questions

Return office visit with end of note stating--

"Total visit over one hour. >50% counseling."


topics of counseling listed in plan

would you still not accept this because the specific amt of time not listed?

thanks
 
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4,466
Location
Milwaukee WI
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99215

I'd give credit for the minimal amount of time noted. If the physician stated "over one hour" I'd give credit for 60 minutes. So this would be coded as a 99215 visit based on counseling/coordination of time.

BUT if the physician had actually spent 70 minutes with the patient, and had documented it as such, you could code 99215 AND 99254. (40 minutes for the 99215 visit, and additional 30 minutes of prolonged service)

This physician needs to learn to be more specific with respect to time.

F Tessa Bartels, CPC, CPC-E/M
 
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