Wiki Discharge summary time documented

[ffslucy]

My office is questioning time documentation on a discharge summary. We were told that Medicare guidelines are that if there is not a time documented on the inpatient discharge summary that we need to code this as a subsequent day. I cannot find any documentation that supports needing the time in the documentation on a discharge summary.

Does anyone have any documentation to support this claim?

 

[Lori Julian]

WPS Medicare has published how to document time for time-based codes. Discharge codes CPT 99238 and 99329 and sited in the article. http://wpsmedicare.com/j5macpartb/departments/cert/2010_0329_time.shtml

Also, the CPT Assistant, August 2013, page 13 stated "These codes do not recognize key components, but rather are reported on the basis of the total time spent by the attending physician or qualified health care professional"