General Surgery Coding Alert

Don't let poor documentation sink your 99238/99239 claims You needn't give up the $75 to $100 that payers allocate for hospital discharge services, but you must document the face-to-face time the surgeon spends with the patient. Take note: If the surgeon performs surgery and discharges the patient during a global surgical period, he cannot report hospital discharge codes (99238, Hospital discharge day management; 30 minutes or less; or 99239, ... more than 30 minutes). But, if the patient is admitted to the hospital and the surgeon does not perform surgery, you can normally report a discharge. Physicians should report discharge codes for:

Trauma not requiring surgery. Surgeons may also report discharge services when they admit trauma patients who do not require surgical treatment.
Nonsurgical conditions. If the surgeon admits a patient for treatment of nonsurgical conditions, you may report discharge services in most cases. For example, the surgeon admits a non-Medicare patient for treatment of postoperative complications. Upon discharge, the surgeon reports 99238. In this case the surgeon would have to append modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the discharge code to describe the service as not included in the global surgical package of the prior surgery.

You should report 99238 and 99239 for "all services provided to a patient on the date of discharge, if other than the initial date of inpatient status," according to CPT. These codes are time-based, and you should report 99239 only if the surgeon spends more than 30 minutes performing discharge services. A. Don't Forego Face-to-Face Meetings The Question: 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 a patient exam before the patient leaves the hospital?

The Facts: 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), but the guidelines imply that physicians should meet with patients during the discharge process.

Face-to-face contact with patients is inherent in all CPT E/M codes, including discharge summaries. Therefore, most coding consultants suggest you be sure that the surgeon documents that he was physically in the room with the patient.

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.

Protect Yourself: Consult your carrier if you're not sure about face-to-face exam requirements, Brink says. Some payers publish specific guidelines that address this topic. HGSAdministrators, a Pennsylvania Part B carrier, printed the following in its E/M Documentation Guideline FAQs:

"When a patient is discharged prior to the daily visit by the physician, a [...]