Wiki Is exam required for Discharge from inpatient

[mrolf]

In order to bill a Discharge CPT code 99238 or 99217 from inpatient or observation does the physician have to do an exam? CMS states a face-to-face visit. It does not give any other criteria. I am having issues with the physicians. They are doing the Discharge Summaries but it does not include an exam. I am reluctant to bill without an exam.
Please advise what to do.

Thanks.

 

[MnTwins29]

CPT passage

This is from the CPT notes for hospital discharge services, 99238-99239: " The codes include, AS APPROPRIATE, final examination of the patient, discussion of the hospital stay, even if the time spent by the physician on that date is not continuous, instructions for continuing care to all relevant caregivers and prepartion of discharge records, prescriptions and referral forms." (Caps are mine, added for emphasis)

Therefore, an examination is not necessarily REQUIRED to bill for discharge services. Would it be good for proper care? Of course. But not an absolute must have in order to do so.

 

[maryann1224@bellsouth.net]

is the time spent for the discharge required to be on the note from the physician too?

 

[MnTwins29]

is the time spent for the discharge required to be on the note from the physician too?

If billing for 99239, then yes, there should be documentation proving he or she spent more than 30 minutes on this service. If no time is documented on the discharge note, then use 99238.

 

[kgoldman CPC COC]

Discharge Time

My understanding of coding for discharge services is that if no time is documented then you can't code it. Oop's no discharge!

Kim

 

[denise.zalusky@providence]

If there is no time documented, then it defaults to the 99238.