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Discharge....Time spent?


Local Chapter Officer
Northwest Ohio
Best answers
Hi all,
I recently attended an E&M presentation that WPS Medicare did and the speaker said a few things that caught me a tad off guard.

The presenter stated that on discharge days, the only requirement is time spent, I know that; however, she stated that if time is NOT documented a discharge cannot be billed?

Does this sound familiar to anyone and if so can you tell me where to locate this information?



True Blue
Midvale, UT
Best answers
Codes 99238 and 99239 do not include key components (ie, history, exam, and medical decision making) in the E/M service. Instead, these codes are reported on the basis of the total time spent by the attending physician for final hospital discharge of the patient. The total time spent providing discharge services on that date is considered, even if the time is not continuous.

CPT assistant December 2009 Volume 19, issue 12