Neurology & Pain Management Coding Alert

Air-tight documentation will guarantee your 99238-99239 claims

When the neurologist reports hospital discharge services, don't take the chance of forfeiting the $75 to $100 that Medicare allots for these codes. Follow these three tips to improve your documentation and your chances at fair reimbursement.

1. Don't Forego Face-to-Face Meetings

The Question: What should you do if the neurologist 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 that you be sure the neurologist 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 discharge day management service can be billed to Medicare if the medical record includes documentation of a service rendered, e.g., instructions for continuing care to all relevant caregivers and preparation of discharge records, prescriptions and referral forms."

The insurer states, however, that it "would expect to see that this is rare, and that the majority of the patients that are discharged are seen face-to-face by the physician for a final examination." In other words, you should always make the effort to document a face-to-face encounter with the patient and physician, or to provide a clear explanation of why such a meeting was not necessary.

Neurologists should report discharge codes (99238, Hospital discharge day management; 30 minutes or less; or 99239, ... more than 30 minutes) in the following scenarios:
  
Trauma not requiring surgery. When admitting trauma patients who do not require surgery, you should report a separate discharge service at the time of the patient's release.

Nonsurgical conditions. If the neurologist admits a patient for treatment of nonsurgical conditions, you may report discharge services in most cases.

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 neurologist spends more than 30 minutes performing discharge services.

You should NOT report hospital discharge services if the physician releases the patient during the global period of a previous surgical procedure.

2. Count Total Time for 99238 and 99239

What you MUST do: Because hospital discharge codes are time-based, the neurologist must document the total time that he spends with the patient during discharge.

How you can improve: The physician should record start and stop times, Brink says. Including start and stop times shows an auditor that you're conscious of time management, whereas documenting total minutes is less definite and accurate.

If you plan to document the total time the physician spent, rather than recording his time in increments, you should make sure you have enough documentation in the record to demonstrate that the physician provided the discharge services.

If, for instance, the neurologist states that he spent 20 total minutes providing all services -- including examining the patient, giving instructions on exercise and completing records -- his discharge notes should detail all services that he provided in that 20-minute period.

And, if the physician reports 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."

The bottom line: Physicians should never use 99239 unless they spend more than 30 minutes in discharge planning and document what they did to justify the time, says Charol Spaulding, CCS-P, CPC, CPC-H, vice president of Coding Continuum Inc. in Tucson, Ariz. " If they do not document any time at all, then the code should default to 99238," she says.

3. Don't Report Discharges for Same-Day Admits

What NOT to do: You should not report the hospital discharge codes 99238-99239 if you admit and discharge a patient on the same date. "For a patient admitted and discharged from observation or inpatient status on the same date, codes 99234-99236 should be reported as appropriate," according to the March 1998 CPT Assistant. This advice still holds true today.

If you discharge an inpatient but admit her to a nursing facility on the same date, you can report both the hospital discharge (99238-99239) and the nursing facility admission codes (99303), according to CPT.