tci E/M Coding Alert - 2013 Issue 4

You Be the Coder: Check For Time Notes on Discharge Coding

Question: The physician admitted a patient and then discharged the patient five days later. Before discharging the patient from the hospital, the doctor spent more than 30 minutes examining the patient as well as giving instructions for continuing care and medication to her family. Should I bill 99239? Answer: You may report 99239 (Hospital discharge day management; more than 30 minutes) provided the physician’s documentation indicates the floor time (the time the doctor spent preparing and dictating the discharge summary) and what the physician did. E/M guidelines indicate that you should use 99239 “to report the total...

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