Cardiology Coding Alert

When you code discharges for patients who have had cardiac diagnostic procedures done in the hospital, your chances of receiving full reimbursement are greater if the cardiologist's discharge-report documentation details the total time he or she spends on the day of discharge providing the discharge services.

You should code hospital discharges with 99238 (Hospital discharge day management; 30 minutes or less) or 99239 ( more than 30 minutes), depending on the length of time it takes to provide services. CPT specifies that you should use 99238 and 99239 for "all services provided to a patient on the date of discharge, if other than the initial date of inpatient status."

For inpatients admitted and discharged on the same day, you should use 99234-99236 for observation or inpatient hospital care, "including the admission and discharge of the patient on the same date."

Coders sometimes have problems with 99238 and 99239 because CPT lacks clarity regarding several aspects of the codes' descriptive information. CPT states that 99238 and 99239 include "as appropriate, final examination of the patient, discussion of the hospital stay, even if the time spent by the physician on that date is not continuous, instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms."

The following scenario may be familiar for many cardiology coders: A cardiologist gives a discharge order for a patient, then talks to the nurses and dictates the summary but does not conduct an actual patient exam before the patient leaves the hospital. The question for coders is whether they should bill 99238 or 99239 if the cardiologist has no face-to-face encounter with patient.

Although CPT does not directly state that face-to-face encounters are necessary during discharge allowing physicians to determine whether such encounters are "appropriate" the guidelines imply that physicians should meet with patients as part of the discharge process.

Face-to-face contact with patients is inherent in all E/M codes, including discharge summaries. Consequently, cardiologists should show in their discharge reports that they were physically in the room with the patient, coding specialists advise.

Indeed, the whole issue of face-to-face encounters with physicians during discharges is controversial, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J.

Consult your carrier if you're not sure about face-to-face exam requirements, Brink says. For instance, Xact Medicare Services, one of Pennsylvania's Medicare payers, requires a face-to-face encounter for discharge services, she adds.

Although seeing your patient prior to discharge may be the best practice, it is not the only deciding factor for billing 99238 and 99239, says coding consultant Charol Spaulding, CPC, CPC-H, vice president of Coding Continuum Inc. of Tucson, Ariz. Physicians may use the hospital discharge codes if they perform any of the criteria indicated in the CPT guidelines, she says.

Code 99238 includes as appropriate final exam of the patient and discussion of the hospital stay, even if the time spent with the physician on that day is not continuous, says Evelyn Gross, CPC, CMM, coding and compliance auditor at Deborah Heart and Lung Center in Brown's Mill, N.J. Physicians spend time coordinating care, speaking with the family and performing other services, so they would not be spending face-to-face time with the patient the entire time with 99238, she says.

Hospital discharge codes are time-based, so accurate documentation of total time spent during discharge is vital.

Whether physicians record start and stop times or the total amount of time spent with the patient depends on how correct they want to be, Brink says. Including start and stop times shows an auditor that you're conscious of time management, whereas giving total minutes is less definite, Gross agrees.

If you're going to document the total time spent rather than record the service provided in increments according to the exact time spent on each part of the discharge service, you should make sure you have enough documentation in the record to support that you provided the discharge services in less than 30 minutes for 99238, Brink says.

The report should include direct statements, such as "I spent a total of 50 minutes in discharge planning," if the physician wants to bill 99239. Cardiologists should never use 99239 unless they have spent more than 30 minutes in discharge planning and documented what they did to justify the time, Spaulding says. "If they do not document any time at all, then the code should default to 99238," she adds.

When two cardiologists in the same practice treat a patient, and one admits the patient and the other discharges him, each would bill for the patient services he or she provided.

If the physicians are part of a group practice and are billing under the same tax identification number, one doctor bills for the admission and the other for the discharge, Brink and Gross say.

For instance, if Dr. Smith from ABC Cardiology Group admitted a patient for chest pain, then he would bill for the initial hospital care using 99221-99223. When Dr. Jones from the same ABC Cardiology Group sees the patient on the date of discharge, she should bill using the hospital discharge codes 99238-99239, Spaulding says. So regardless of whether the physicians are in the same practice group, they each should bill for their own services, she says.

Sometimes in a group practice that is under one tax identification number, one cardiologist will discharge and another will write the discharge summary, Brink says.

In this case, the discharging physician bills for the discharge. Whoever dictates the discharge summary is under the auspices of the discharging physician. If the discharging physician wants to sign off on the discharge summary (written by another physician in his group) without reading it, he or she takes full responsibility for the discharge summary, Brink says.

This would vary only when a physician transfers care to another doctor. If this occurs, then only the physician accepting responsibility for the patient would be able to use the discharge codes, Spaulding notes.

For example, if an orthopedist admits a patient to the hospital because she had a fractured pelvis (808.x), the orthopedic physician would do the history and physical and care for the patient until she is stable. If the patient develops arrhythmia (427.9) during the post-op period, the orthopedic physician would transfer the care to a cardiologist, who treats the patient for arrhythmia.