Wiki 99238 or 99239?

[jdibble]

I just started auditing the Hospitalists charges for our hospital and I need some guidance. Since Discharge services are time based, does the documentation that the doc does have to state somewhere the total time spent on the discharge? Wouldn't that be needed to code? None of these docs have documented time in there reports but have chosen the 99239 over the 99238.

Any help would be great!

Jodi Dibble, CPC

 

[Orthocoderpgu]

The time must be documented by the docs. If they don't, it's 99238 since they would need to document the time to get the 99239. My docs almost never include the time involved doing the discharge either. I think most don't include it unless it goes over 30 minutes. Remember, if it's not documented, it's not done. Can't show that 99239 is correct if there is no time documented.

 

[jdibble]

Thanks for the response. That is what I thought but I justed needed to confirm it.