General Surgery Coding Alert

General surgery coders may not use hospital discharge services codes often, but when they do, they should know how to report them accurately. Your chances of receiving full reimbursement are greater if the documentation in the discharge report includes details on the total time spent on the day of discharge by the physician who provides the discharge services. Remember that surgeons may not bill hospital discharge services when they perform an operation and the procedure has a global period. In other words, surgeons can only bill discharge services when the patient has been admitted but has not had surgery, coding experts say.

Such situations could include: Postoperative complications. When a surgeon readmits a patient for a postoperative complication, such as a wound infection (998.59) after hernia repair surgery, and treats that complication without performing additional surgery, he can report discharge services.(Although private payers may cover discharge services for postoperative complications, Medicare may have different requirements. Consult your local Medicare carrier's review policy before billing for discharge services under these circumstances.) Trauma not requiring surgery. Surgeons may also report discharge services when they admit trauma patients, such as burn patients, who do not require surgical treatment. Nonsurgical conditions. If a surgeon admits a patient for treatment of nonsurgical conditions like anticoagulant therapy, discharge services may be appropriate. 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. 1. Don't Forego Face-to-Face Meetings 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 [...]