Wiki Discharge Time Documentation Requirement

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aguelfi

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Does anyone have documentation to provide to me that states the physician must document the time spent with the patient when billing discharge services 99238 and 99239
 
If billing 99238, time does not need to be documented. If billing 99239, time DOES need to be documented. All time based codes need time to be documented because, as the old coding adage goes, "if it's not documented, it didn't happen".
 
I know all about the golden rule. Unfortunately it doesn't help me here. CPT, First Coast Service Options, and CMS do not have anything in writing that states 99239 must include in the time spent. Yes it's implied however I get the argument of "show me where it states this". Using a different Medicare carrier doesn't really help me. If FCSO or CMS doesn't state it, the doctors are leery of listening to it. When you compare other codes, i.e., critical care, they do specifically state time is required where the discharge codes don't. This is my dilemma.
 
We also have, from NGS, clarification for time based codes including discharge codes 99238-99239. So, if your MAC hasn't issued a clarification, maybe you could request that? NGS states that any time you use time based codes you should include the time spent at the very least and preferably the start and stop time. They know however, that in hospital it's not that simple. You spend time away from the patient doing things for the patient, so they say that a notation of time spent is acceptable. Sorry, can't be more help than that.
Good luck.
 
abenson said:
I know all about the golden rule. Unfortunately it doesn't help me here. CPT, First Coast Service Options, and CMS do not have anything in writing that states 99239 must include in the time spent. Yes it's implied however I get the argument of "show me where it states this". Using a different Medicare carrier doesn't really help me. If FCSO or CMS doesn't state it, the doctors are leery of listening to it. When you compare other codes, i.e., critical care, they do specifically state time is required where the discharge codes don't. This is my dilemma.
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It is clearly stated in CPT. Page 16 of the 2010 CPT Professional edition. "Hospital discharge day management codes are to be used to report the total duration of time spent by a physician for final hospital discharge of a patient"...
 
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