If the discharge orders, exam & everything else is there, just not the time, then 99238 is appropriate.
Q: Do I have to document the time I spend discharging a patient? If, for instance, I spend less than 30 minutes doing the discharge, do I need to state, "15 minutes were spent discharging the patient, discussing …"?
A: You need to document time spent in discharge services only if you bill a 99239, which is the discharge code to use when you spend more than 30 minutes on discharge services.
According to CPT coding guidelines, you must document the duration of time spent for any time-delineated codes, which include 99239 as well as critical care codes, prolonged services codes, and codes based on counseling and coordination of care.
You do not have to document time spent when billing the discharge code 99238, which you use to designate spending less than 30 minutes. Because there is no specific amount of time that you have to meet to bill that code, you just need to document the discharge services provided.
The 99239 code, on the other hand, has a time threshold you must meet to bill that code, so your documentation has to support the fact that you spent more than 30 minutes.