Reader Questions: Avoid the Common Mistake of Under-Reporting 99239

Question: When our physicians discharge patients from the hospital, is 99238 the only code we should report for all the services that day?

Maryland Subscriber

Answer: Yes, a hospital discharge code is the only E/M code you should report for your physician's services on the day of discharge. If the physician happened to perform some other procedure or service before discharging the patient (for example, a fine needle biopsy of a thyroid nodule), you can report the appropriate code(s) for that service separately.
 
Not so fast: Many coders automatically report 99238 (Hospital discharge day management; 30 minutes or less) when they see a discharge in the physician's documentation, but 99239 (... more than 30 minutes) may often be more appropriate - and it pays more.
 
Documented time is essential: Hospital discharge codes report the total duration of time the physician spends preparing the patient's discharge, and the time doesn't have to be continuous. Discharge services can include "final examination, discussion of the hospital stay, ... instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms," according to CPT.
 
Often physicians don't adequately document all the time spend and services involved with a discharge, and this leaves you no choice but to report 99238. To make sure you're recouping all you deserve for your physician's time, instruct your physicians to carefully record the details and length of time they spend on discharges. Ten minutes here and there can quickly add up and increase your level of service to 99239.