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Discharge Exam

  1. #1
    Default Discharge Exam
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    For Inpatient care in a hospital, is there any acceptances for the Doctor's to NOT do an exam on a discharge summary? Can anyone help us?

    Thank you!

  2. #2
    No exam elements have to be documented in order to bill 99238 or 99239, these are stictly time based code.

    Is that your question, can you bill if they don't document an exam? If so the answer is yes you can.

    Laura, CPC

  3. #3
    I'm a bit confused. Did you mean to say discharge summary? If you are talking about discharge day management it is as Laura said, you do not need an exam. You can bill 99238 for discharge day management without even stating how much time was spent on it. You can bill 99239 ONLY if time is documented and greater than 30 minutes. You cannot bill based on a discharge summary, you need a separate note for the discharge day.
    Karolina, CPC, CPMA, CEMC

  4. Default
    Can you elaborate on your statement, "you cannot bill based on a discharge summary, you need a separate note for the discharge day."?

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