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Orthopedic Coding Alert

Reader Questions:

1 Code Covers a Day's Work in Discharge

Question: When our physicians discharge patients from the hospital, is 99238 the only code we should report for all the services that day?

Idaho Subscriber
Answer: Yes, a hospital discharge code is the only E/M code you should report for your physician's services on the day of discharge. If the orthopedist happens to perform some other procedure or service before discharging the patient, you can report the appropriate code(s) for that service separately.
Some coders automatically report 99238 (Hospital discharge day management; 30 minutes or less) when they see a discharge in the physician's documentation, but 99239 (... more than 30 minutes) may often be more appropriate - and 99239 pays more, so it can help you stay compliant and optimize your reimbursement.
Hospital discharge codes allow you to report the total duration of time the physician spends preparing the patient's discharge. But what some coders don't know is that the time that the physician spends doesn't have to
be continuous.
Discharge services can include "final examination, discussion of the hospital stay, ... instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms,"
CPT states.
Often, physicians don't adequately document all the time spent and services involved with a discharge, leaving you no choice but to report 99238.
To make sure you're recouping all you deserve for your physicians' time, instruct them to carefully record the details and length of time they spend on discharges. Ten minutes here and there can quickly add up and increase your level of service to a 99239 if the physician documents his services appropriately.

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