Gastroenterology Coding Alert

Question: To ensure that you’re properly reporting the hospital discharge codes, what documentation detail is a good starting place?

Codify Subscriber

Answer: When your gastroenterologist performs hospital discharge services, your options are as follows:

• 99238, Hospital discharge day management; 30 minutes or less
• 99239,  ... more than 30 minutes.

Looking at the code descriptors, you can see that the choice between the two codes depends on the time your provider spends on the discharge services. So, you will look in the documentation for notes about the time the physician spent with the patient. Always check the chart prior to reporting 99239 to ensure that your doctors have properly documented the time required to report this code.

Note: If there is no time notation in the discharge service documentation, you must code 99238 rather than 99239.

Proper time documentation for all discharge services in the medical record will protect the physician regardless of what the current insurance requirements are or may change to. These requirements do change from time to time depending upon contracts and CMS carriers. Getting in the habit of always noting the time for discharges will protect the physician in every situation.

The documentation should also illustrate the final physical examination of the patient along with pertinentdischarge information. This could be instructions for care, a follow-up appointment schedule, home care contacts and tasks, or any number of other relevant information around the successful discharge of the patient.