Neurology & Pain Management Coding Alert

Question: Our neurologist spent more than 30 minutes examining a patient and giving instructions for continuing care and medication before discharging her from the hospital. Should I bill 99239?

Nevada Subscriber

Answer: You may report 99239 (Hospital discharge day management; more than 30 minutes), provided documentation indicates the total time the attending physician spent on discharging the patient and what discharge services the physician provided, such as final examination of the patient, discussion of the hospital stay, instructions for continuing care to all relevant caregivers, as well as preparation of discharge records, prescriptions, and referral forms.

Reminder: The time your neurologist spends on discharge planning doesn't need to occur in one continuous block. You should count all time spent in discharge day services on the day he or she provides face-to-face services to the patient.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.