Wiki Hospital Discharges

[tlaubhan]

What documentation is needed in order to bill CPT 99238/99239? Is a one liner sufficient? The provider and I discussed this today and since we disagree, I thought I would post this question for any feedback.

I stated that to bill a 99238-99239 I would need a discharge summary. The summary should include the reason why the patient was in the hospital, primary diagnosis, any additional diagnosis, where patient is discharged to, plan of care, medications, etc… My provider stated that is not true as all of this info is in the patient's file, thus a one liner is sufficient.

Any feedback is greatly appreciated!!

Thanks,

 

[Kisalyn]

I don't have a CPT book in front of me, but if I remember correctly, it's a time based CPT code. I've noticed that they vary at each hospital, but usually the reports include the admission diagnosis, discharge diagnosis, course of treatment while in the hospital and a list of procedures and consultants.

My provider's discharge summaries are usually half a page to a page long. All I look for is whether the aggregate time spent was greater than 30 minutes. You might want to check with the hospital to see if they have any requirements.

 

[kathymoon]

I just located this from Medicare (J8 MAC) "Discharge management must inclue documentation of a face-to-face evaluation and management (E/M) service between the attending physcan and the patient." Also, "the provider must clearly indicate in the patient's medical record the total duration of time spent when performing these services."

I've always found that CMS' Evaluation and Management Service Guide is extremely useful when needing E/M guidance. Hope this helps.