Urology Coding Alert

Question: The urologist admitted a patient and then discharged the patient five days later. Before discharging the patient from the hospital, the urologist spent more than 30 minutes examining the patient as well as giving instructions for continuing care and medication to her family. Should I bill 99239?

Answer: You may report 99239 (Hospital discharge day management; more than 30 minutes) provided your urologist's documentation indicates the floor time (the time the physician spent preparing and dictating the discharge summary) and what the physician did.

E/M guidelines indicate that you should use 99239 "to report the total duration of time spent by a physician for final hospital discharge of a patient." Services may include examining the patient, discussing the stay, instructing caregivers on continuous care, and the related paperwork, such as the discharge records, prescriptions, and referral forms, the guidelines state. When  you calculate the time involved on discharge day, remember that CPT says the time doesn't need to be continuous.

Reminder: You would use 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components...) for the initial hospital care work.