Part B Insider (Multispecialty) Coding Alert

Make sure to document the surgeon's time if you bill 99238-99239

Many surgeons believe they can never bill for discharge planning (CPT codes 99238-99239)--and that belief is costing them money.

Reality: In fact, you can bill for a surgeon's discharge services as long as the surgeon didn't perform a procedure with a global period, says Charol Spaulding with Coding Continuum in Tucson, AZ. The global period for any surgery will include discharge services. But if the surgeon admitted the patient for a non-surgical service, such as anticoagulant therapy, then the surgeon can still bill a discharge.

You can also bill 99238-99239 for a surgeon's discharge if the surgeon admitted a trauma patient who didn't require surgery, such as a burn patient. Or if the surgeon discharged a patient after surgery, but then had to readmit the patient because of surgical complications such as wound dehiscence (infection), then you can bill for the second discharge.

Also, when the surgeon performs a minor procedure that has no global period, sometimes the patient must stay in the hospital overnight because of co-morbidities.

Not just for surgeons: The same discharge planning rules that apply to surgeons apply to other physicians as well, says Catherine Brink, president of Healthcare Resource Management in Spring Lake, NJ. You should document all the things the physician did, including time spent with the patient. If you want to bill the higher-paying CPT 99239 , you need to document that the physician spent at least 30 minutes dealing with the patient's discharge. The 30 minutes don't have to be continuous. (See PBI, Vol. 6, No. 22.)

You shouldn't need a modifier with 99238-99239, because the surgeon is treating a different problem that's not part of the global package, Brink says.