Wiki Hospital discharge codes 99238 & 99239


Best answers
I'm seeking feedback on the time statement requirement for hospital discharge code 99238. I interpret the guideline to state that time must be documented for BOTH 99238 and 99239. However, I have a co-worker that states that guideline only requires the time statement (30 minutes or greater) when billing the 99239. After providing reference to the guideline below, I'm told that if no time is documented, we can automatically assume it was less than 30 minutes and bill a 99238.

Whereas, another co-worker asked if time is not documented for a 99238/99239, can a daily round (99231-99233 or 99224-9226) be billed if documentation supports the required components for this category?
No time needed for 99238

As a practical matter, time does not need to be documented for 99238.

I have spoken to multiple physicians of many specialties and all of them say the same thing: they ALWAYS spend 31+ minutes when discharging a patient and reading their notes it's obvious that they have with all that is needed to be documented.

It would be nice for the physician to always document the amount of time spent, but that does not always happen.

Because these two codes are based on time only, if time is not documented, the doc gets the lesser of the two codes as a practical matter. And if they have not documented any time, by the time you see it, they will have seen so many other patients that there is no way for them to go back and document the approximate amount of time.

Since these codes are based on time, you cannot use another code with the three key components. You have to bill a discharge code.

If they don't dictate the time, they get the lesser of two codes.
Hi Very late reply hopefully someone sees it. To my understanding that is correct that if there is no time documented the provider gets the lesser code 99238, I was wondering if that's actually documented anywhere ? I cannot find anything but sure would love it if there was something in writing. Thanks