99238 required documentation

[Hannahmcelroy15@gmail.com]

Hello,

Is "face to face" required in the documentation for a discharge summary in addition to the time?

 

[Cmama12]

According to CPT Assistant, due to the wording " ..include, as appropriate, final examination of the patient.." a face-to-face service is not required.

 

[TThivierge]

Hannah
There are discharges services for inpatient status, nursing facilities and newborn babies...usually providers need to see each patient face to face to bill a certain CPT code. Now each medical documentation should have separate paragraph on discharge status to recommend a future visit or more care , Etc. that needs to be documented. But telehealth services on phone or video to release a patient equal to a discharged is here now.
Yes, you can use telehealth for patient discharge, but typically the specific Hospital Discharge Services codes (CPT 99238 and 99239) are used in a limited capacity for inpatient discharge. The services must be furnished using real-time audio and video telecommunications, (add modifier 93 or 95)and specific coding guidelines must be followed to ensure proper reimbursement.
I hope this data helps you
Lady T