As you know doubt know, there’s a different coding option for admission and discharge on the same date. But for discharge on a different date, CPT is mainly concerned with the time spent on performing the discharge service. The excerpts from CPT Assistant below may help clarify what’s required for 99238 and 99239.
Evaluation and Management Services. CPT® Assistant.
July 2011; Volume 21: Issue 7
Question: When reporting hospital discharge day management services (99238, 99239), is the final examination of the patient required?
Answer: No. The Hospital Discharge Services guidelines in the CPT codebook state that the hospital discharge day management codes are to be used to report the total duration of time spent by a physician for final hospital discharge of a patient. 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 care givers, and preparation of discharge records, prescriptions, and referral forms. The reference to the phrase “as appropriate” has been stated in the CPT guidelines since CPT® 1996 and addresses the circumstance wherein patient examination was either not necessary or not performed but the other element(s) were provided.
Evaluation and Management, 99238, 99239 (Q&A) (January 1999). CPT® Assistant.
January 1999 page 10
Coding Consultation
Question
If my physician saw a patient in the hospital and performed a subsequent hospital visit, and then discharged the patient from the hospital later that same day, could he report both the subsequent hospital visit and the hospital discharge code?
AMA Comment
The hospital discharge day codes 99238 and 99239 include all the E/M services performed on the day of discharge. Therefore, it is not appropriate to separately report a subsequent hospital care code (99231-99233) if a hospital care discharge service (99238 or 99239) is performed on the same day.