tci General Surgery Coding Alert - 2017 Issue 9

Reader Question: Note Time for Discharge Or Lose Pay

Question: We have a surgeon who never documents time for a hospital discharge. How should we code the service, and is there anything we can do to make sure we're coding appropriately? Arkansas Subscriber Answer: If your surgeon doesn't document time for a hospital discharge, your only recourse is to bill 99238 (Hospital discharge day management; 30 minutes or less). This is the lesser code, and is the only code you can justify if you don't have written evidence that the surgeon spent more than 30 minutes, which would justify reporting 99239 (... more than 30 minutes). As to...

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