General Surgery Coding Alert

Question: We have a surgeon who never documents time for a hospital discharge. How should we code the service, and is there anything we can do to make sure we're coding appropriately?

Arkansas Subscriber

Answer: If your surgeon doesn't document time for a hospital discharge, your only recourse is to bill 99238 (Hospital discharge day management; 30 minutes or less). This is the lesser code, and is the only code you can justify if you don't have written evidence that the surgeon spent more than 30 minutes, which would justify reporting 99239 (... more than 30 minutes).

As to what you can do to accurately code your surgeon's work, perhaps informing the surgeon of the coding and cost differential would encourage better documentation. Medicare pays $73.57 for 99238, compared to $109.10 for 99239 (facility national adjusted amount, conversion factor 35.8887).

Proper time documentation for all discharge services in the medical record will protect the surgeon 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 surgeon in every situation.

Tip: You can help your surgeons to remember to record time by adding a line to the provider's template for start/stop or total time spent on discharge services.

The documentation should also illustrate the final physical examination of the patient along with pertinent discharge 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.