On the discharge summary, if the physcian does not document the time, then I should use the 99238?
99238 is for 30 minutes or less... so if the physician DOESN'T put a time a greater than 30 minutes, it's assumed to be less than 30 minutes and go with 99238. You don't HAVE to document "I spent 20 minutes..." etc though it's nice to do, but not required.
For 99239- greater than 30 minutes. You always have to have the time documented to support this discharge code.
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