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Wiki HELP! Question regarding 99238

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dokeef01

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I realize that 99238 is the lower E/M service billed for a hospital discharge. I am confused on the documentation requirements. It states that code includes discussion of the hospital stay. Is it appropriate for a physician to just have a line down the physical exam of a newborn and call that a discharge? They do not include any kind of d/c summary or status of the baby such as feeding well, voiding and stooling, etc.

Thank you so much if you could please respond.
 
No. There should be an appropriate documentation of discharge summary to bill the service.
 
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