The discharge cpt code plays an important role when coding for discharge services. This code ensures that the healthprovider gets the maximum reimbursement for the services and resources they have spent on a patients discharge. The properly coded discharge process does not only ensure proper reimbursement but also ensures that its compliances with the healthcare standards.
Therefore, it is important for healthcare professionals and medical billing experts to understand how proper discharge coding is done.
However, there might be a lot of people who are beginners in the industry who might do not know what is discharge cpt code and how it is coded.
So to teach and refresh for those who already know we have explained the entire process of coding discharge services below. Stick with us till very end as we have also explained what actually discharge cpt code.
What is the Discharge Cpt Code?
A discharge cpt code is used to record the services a healthcare professional or a physician has provided to the patient when discharging from hospital or any facility with the same healthcare setting.
This process involves all the treatment provided to the patient, ensuring that whether they are stable for discharge or not, discharge instructions, and properly handing them of for further discharge or follow-up care if they need it.
The primary CPT code for discharging is CPT 99238 and CPT 99239 which varies upon inpatient and outpatient services according to the patient. The choice of the code depends on the fact that how much time the healthcare provider or the doctor has provided the physician during the discharge process.
However, to make it more simple for you, I have exaplined it more ahead.
CPT 99238 is used if the physician or the doctor has spent 30 minutes or less while discharging the patient.
CPT 99239 is used if the physician or the doctor has spent more than 30 minutes while discharging the patient.
The use of both the codes require patient documents which mean they are only implied to those patients who are officially discharged from inpatient care.
A step-by-step guide to code for discharge services
Precise discharge coding requires effort and complete documentation of the time and services song with the complexity of the process involved with the discharge process.
Identify the correct discharge CPT code
The first step in effectively coding for the discharge services to determine the correct discharge cpt code. The correct code is determined based on the time spent with the patient and the level of care provided.
CPT 99238 is used if the physician or the doctor has spent 30 minutes or less while discharging the patient.
CPT 99239 is used if the physician or the doctor has spent more than 30 minutes while discharging the patient.
While coding correctly for the discharge services you must keep in mind that the time spent with the patient is not only the time taken to discharge the patient but it also involves the time spent in reviewing the patient’s progress, prescribing medicines, and making any required follow-up arrangements.
Document the discharge time and services provided
Apart from the correct code proper documentation is also important for cding discharge services properly. This requires the healthcare provider to event record the time spent with the patient while discharge process. A detailed breakdown of this time is given below:
Time spent with the patient: The physician or the healthcare provider should notice and record the time spent with the patient on discharge care, including discussions, instruction on medications, follow-up appointments, and any other necessary health instructions.
Patient’s condition: The patient’s clinical status is also to be documented to justify the discharge services provided.
Instructions given: If the physician or the doctor has added any home care or follow up instructions they are also to be included in the document.
Complexity of the case: For more complicated cases, additional details about the patient’s treatment and care plan will be necessary to justify a longer discharge time and the use of CPT 99239.
Ensure Compliance with Payer Requirements
Each insurance company might have different requirements for filing the claim, so you must ensure that the claim aligns with the payer requirements. For example some insurance companies want some specific documents to support a claim whereas some accept that claim without that document, so you need to check the regulations of your payer.
Check for Other Billing Codes
In some cases it happens that the patient wants counseling or coordination of care then in this case the provider must code these services and ensure that they are properly documented and correctly coded as they require other billing codes to be added other than the discharge ones.
Use the Correct Diagnosis Code
Along with the discharge cpt code, it is important to include the correct diagnosis code that shows the patients condition at discharge time. It ensures that the services provided are accurately linked to the patient’s diagnosis which further supports the need for discharge services.
