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Wiki discharge code 99238 no exam done

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doggieluv

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On an inpatient discharge, the Dr. did not do an exam nor document the time. He gave a good history, lab data, & description of hospital course with DC meds & instructions. Can I bill for 99238? Thanks
 
Key elements of discharge summaries, according to the Society of Hospital Medicine, are as follows:
• Problem that led to hospitalization
• Key findings and test results
• Final diagnoses (primary and secondary)
• Brief hospital course
• Condition at discharge
• Discharge destination
• Medications at discharge
• Follow-up appointments and proposed management plan
• Anticipated problems and suggested interventions
• Pending laboratory work and tests
• Recommendations of subspecialty consultants
• Documentation of patient education
• Name and 24-hour phone number for hospital physician records.
March ACP Hospitalist, copyright © 2009 by the American College of Physicians


Without time documented we default to the 99238
 
Thank you so much. Not being an inpatient coder, i really appreciate your comprehensive answer.
 
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