Internal Medicine Coding Alert

Question: Our state Medicaid denied 99239 on the last day of the hospitalization because the patient died that day. The representative said that we could only charge for time or a 99232 or 99233. Is there a distinctionbetween a live or deceased discharge?

South Dakota Subscriber

Answer: Although CPT does not make one, carriers may. While the hospital discharge services (99238, 99239) instructions do not require the physician to perform all listed services, some carriers have applied this interpretation.

You can report 99238 (Hospital discharge management; 30 minutes or less) or 99239 (... more than 30 minutes) when the physician provides any of the services listed in the discharge day management notes, according to the AMA.

"The appropriate hospital discharge code, 99238-99239, can be reported in the case of a patient death when the physician performs any of the criteria indicated in the guidelines ... under Hospital Discharge Services (e.g., counseling, preparation of discharge records, etc.)," according to CPT Assistant March 1998.

Some carriers, however, require the physician to perform all the items described in the hospital discharge services instructions to report 99238 or 99239. For pronouncement of death, the attending physician should use an E/M code based on the elements performed that day, according to Peter A. Hollmann, MD, medical director for Rhode Island Blue Cross Blue Shield.

At the CPT 2009 symposium in Chicago, Hollmann said to code a scenario similar to the one that you describe using the key components. For instance, if the internist had performed an expanded problem-focused interval history, an expanded problem-focused physical, and moderate medical decision making, you would assign 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components ...).

Alternatively, you could choose the subsequent hospital care code using time as the key factor, provided documentation shows that counseling and/or coordination of care makes up the majority of the floor/unit time that the physician spends on the patient. The chart note would need to indicate the total subsequent care time and the counseling minutes, and to provide sufficient documentation describing the topics discussed. For instance, if the physician spent 35 minutes at the patient's bedside and on the patient's hospital floor or unit and more than 17 and a half of those minutes were on counseling and/or coordination of care, you could report 99232 (... Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit).