Wiki time reporting for cpt 99239

[JulieAnne1970]

The coding guidelines for reporting 99239 are that the provider must report more than 30 minutes in the medical record. I was trained that in order to receive reimbursement for 99239 the provider must report specific time 31 minutes or over.
Where can I find this specific guideline?

Thanks
Julie

 

[jdibble]

99238 is for discharges up to and including 30 minutes. 99239 is for a discharge over 30 minutes. The documentation must show that the doctor spent more than the 30 minutes discharging the patient in order to code 99239. How the doctor documents could depend on your MAC or how your facility requires the time documented. We require that our doctors document the total time spent in discharging the patient as opposed to just stating they spent "over 30 minutes" or "over 31 minutes".

The following is a link to one MAC on what documentation they require:

http://www.wpsmedicare.com/j8macpartb/departments/cert/2010_0329_time.shtml

Physicians must use the total duration of time spent in order to select the code that reflects hospital discharge day management services provided for Medicare beneficiaries. For this reason, the provider must clearly indicate in the patient's medical record the total duration of time spent when performing these services. For hospital discharge day management; 30 minutes or less, use CPT code 99238. To report 30 minutes or more, use CPT code 99239. To learn more about these and other Evaluation and Management (E/M) services, visit our E/M webpage.

Check you Medicare carrier too to see what they may require.

Hope this helps.