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Wiki help with codes 99238-99239

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cooper1

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I've not coded discharges before. I need help knowing what all needs documented for a discharge. I know the times need documented in order to code 99239 but what else needs to be done?

Thanks in advance
Tracey
 
INCLUDES: discharge instructions, final preparation of the patient's medical records, provision of prescriptions/referrals, as needed and review of the inpatient admission

Normally in a discharge, or also called clinical resume, the discharging physician dictates a summary of their hospital course, from admission to discharge, including presenting illnesses, surgeries, if applicable, complications, if applicable, medications, etc..etc.. The E/M components do not apply to these codes.
 
If I have a surgeon who admits a pt then the pt has a surgery by him/her then is discharged a day or so later can I bill for a discharge or is this part of the global period?

Tracey
 
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