General Surgery Coding Alert

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

For patients admitted as inpatients 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.

Coding experts recommend these three strategies for improving payment for discharge services.

What should you do if the surgeon gives a discharge order for a patient, then talks to the nurses and dictates the summary but does not conduct an actual exam on the patient before the patient leaves the hospital? The question for coders is whether they can bill 99238 or 99239 if there is no face-to-face encounter with patient.

Although CPT does not directly state that face-to-face encounters are necessary during discharge leaving it to 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 CPT E/M codes, including discharge summaries, so surgeons should show in their discharge reports that they were physically in the room with the patient, coding specialists says.

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, Empire Medicare, which is New Jersey's Medicare payer, does not require a face-to-face encounter to charge for discharge services, she adds.

Although the physician should see his or her patient prior to discharge, 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. Aphysician may use the hospital discharge codes if he performs any of the criteria indicated in the CPT guidelines, she says.

Code 99238 includes, as appropriate, the final patient exam 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, writing discharge orders, and performing other services, so they would not be spending face-to-face time with the patient the entire time with 99238, Gross says. For instance, during a discharge for a patient who was admitted for a complication from surgery to remove a stomach ulcer, the surgeon may examine the patient and then discuss diet and care with the family without the patient present. In this case, the surgeon should document the examination, the coordination of care, and the total time spent to support billing 99238 or 99239.

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

The surgeon should record start and stop times, 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 time increments, you should make sure that you have enough documentation in the record to support that you provided the discharge services within 30 minutes or less for 99238, Brink says. In the example above, for instance, if the surgeon notes that he spent 20 total minutes providing all services, including examining the patient, giving instructions on medication and diet, and completing records, his discharge notes should give details on all services provided in that 20 minutes to support billing 99238.

And, if the physician wants to bill 99239, the discharge report should include direct statements such as, "I started the discharge service at 9:00 a.m. and finished at 9:50 a.m." or "I spent a total of 50 minutes providing discharge planning and other services." Physicians 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 stresses. "If they do not document any time at all, then the code should default to 99238," she says.

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

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

For instance, if Dr. Smith from ABC General Surgery Group admitted a patient for a workup for a gall-bladder problem, he would bill using 99221, 99222 or 99223, depending on the level of service. When Dr. Jones from the same ABC General Surgery Group sees the patient on the date of discharge, she should bill using the hospital discharge codes 99238-99239, Spaulding says. So it doesn't matter if the physicians are in the same practice group as long as they are each billing for their own services, she says.

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

In this case, the discharging surgeon 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 takes full responsibility for the discharge, Brink says.

The only time this would vary is when there was a transfer of care from one service to another. If this occurs, the physician accepting the patient would be able to use the discharge codes, Spaulding says.

For example, if a patient is admitted for a complication for a hernia repair, the surgeon would do the history and physical and care for the patient until he is stable. If, during the admission, the patient develops arrhythmia, the surgeon would transfer the care to a cardiologist who treats the patient for the arrhythmia.

The patient's care now belongs to the cardiologist who would have the responsibility for the patient's discharge.