Orthopedic Coding Alert

CPT specifies that 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." These codes are time-based, so you should report 99239 only if the orthopedist spends more than 30 minutes performing discharge services.
 
Coding experts recommend these three strategies for improving payment for discharge services.

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

Snag: What should you do if the orthopedist 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?
 
Reality: 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, so most coding consultants believe that orthopedists should document that they were 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.
 
Smart move: 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."

2. Count Total Time for 99238 and 99239

Smart: Because hospital discharge codes are time-based, the orthopedist must document the total time that he spends with the patient during discharge.
 
Smarter: 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.
 If you plan to document the total time spent, rather than recording the service provided in time increments, you should make sure you have enough documentation in the record to demonstrate that you provided the discharge services within 30 minutes or less for 99238.
 
If, for instance, the orthopedist 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

Warning: You should not report the hospital discharge codes 99238-99239 if you admit and discharge a patient on the same date. According to the March 1998 CPT Assistant, "For a patient admitted and discharged from observation or inpatient status on the same date, codes 99234-99236 should be reported as appropriate."
 
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.