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Thread: Discharge Exam

  1. #1
    Join Date
    Apr 2007

    Default Discharge Exam

    AAPC: Back to School
    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
    Join Date
    Apr 2007


    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
    Join Date
    Apr 2007
    Boston, MA


    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. #4


    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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