Discharge summary time

Is it acceptable for the doctor to state "more than" or "greater than" 30 minutes for code 99239? If so, can you direct me to documentation stating it is ok to use this wording.

thank you

Maria Gonzales CPC

Highmark says:

please note that hospital discharge day management codes 99238 (30 minutes or less) and 99239 (more than 30 minutes) are time based so it is imperative that the medical documentation reflect the total time spent by a physician during the discharge of a patient.

I would interpret "reflect the total time" as meaning that it must say 35 minutes, 32 minutes, 45 minutes, etc.

Highmark says

I agree. Put an exact time in. It gives the auditors something to ponder. I'm a passive-aggressive guy so when I time my notes, op permits, etc, I used my computer system time, 1044, 0531, 2156, etc. My hospital EMR CPOE dates and times my orders for me (finally!)

The downside of course

to EMR's tracking times is that doctors overestimate the time spent doing things. I would bet that if we audit the times that most docs who report 99239 do not spend over 30 minutes on the unit doing the discharge- 10 min with the patient, 10 min on the unit dictating, reconciling meds, etc. Same as our use if time in the office- how can a doc seeing 40 patients a day spend 40 minutes with one patient???

D/C Diagnosis

Do you by chance have the MLM # for D/C- the one that states you must document all the diagnoses ( facility coding)?
Thanks much...
Katie

discharge time

do you know the source for documenting all diagnoses for the stay?
Thanks... Katie