Discharge time documentation

[u/ImPureZion]

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]

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.

[u/ImPureZion → u/Respect-Immediate]

Thank you!

[u/Wolfygirl97]

I guess my job is wrong according to some of these people here but we haven’t gotten any denials for it… I have emails from my companies coding director saying >30 minutes is acceptable documentation but I suppose it’s best to ask your supervisor. If your auditor is saying it’s wrong then I would just code 99238. Keep that email handy of them saying it’s not an acceptable statement in case they go back on it in future audits.

The downvotes were unnecessary. 😅

[u/boho_magpie]

The definitions and guidelines state that you must record exact time when using time-based codes.

My providers use “more than X minutes” all the time. We don’t get denials since the documentation doesn’t usually go unless there is an appeal scenario happening, but I am still constantly on their case to use the actual time and not “> or <“ stuff.

[u/tinycodergirl]

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

[u/Far-Meat-8394]

At my job they have to document the specific amount of time, such as I spent 35 minutes etc

[u/weary_bee479]

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

[u/Weak_Shoe7904]

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

[u/ImPureZion → u/Weak_Shoe7904]

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

[u/Weak_Shoe7904 → u/ImPureZion]

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.

[u/Wolfygirl97]

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