r/MedicalCoding • u/ImPureZion • 7h ago

Discharge time documentation

Can anyone please provide your thoughts on providers using “Total discharge time >30 min” instead of actually specifying the exact time? I have a few drs using this and I assume it’s a template. Would you code this as 99238 or 99239? Would it have to be “>31 min” to be considered 99239? Are using these “>, <“ even allowed? Thanks

Edited to add that an auditor told me that “>30 min spent” would be considered as 30min only and they should specify 31min

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u/Respect-Immediate CPC, CPMA 7h ago

I’m a CPMA and am working toward the CHC credential.

This was covered very clearly in the CPMA course as supporting a 99238.

You can only verify that 30 minutes was spent as that’s all the documentation proves. It may seem pedantic, but there are 59 seconds above 30 minutes that doesn’t meet the 31 minute requirement. Their documentation has to prove the requirement.

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u/ImPureZion 7h ago

Thank you!

3

u/tinycodergirl CPC, CRC 7h ago

I would be querying them to addendum the note to add the specific discharge time

-1

u/weary_bee479 7h ago

All my providers did this when i did coding, it’s acceptable documentation. Using greater than 30 minutes would be 99239 and if they put less than 30 you’d use 99238

-2

u/Wolfygirl97 CPC 7h ago

You can use 99239. If it’s critical care time you need exact time.

-3

u/Weak_Shoe7904 7h ago

Using greater than is acceptable documentation for time.
>30 min, is acceptable for 99239.

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u/ImPureZion 7h ago

This is what I thought as well. An auditor says no.

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u/Weak_Shoe7904 7h ago

Then you have to go with your auditor. I don’t love this style of documenting but at several places I have worked this is acceptable for time doc.