99238 Hospital discharge day management; 30 min.
99239 more than 30 min
Hospital discharge day management codes 99238 (30 minutes or less) and 99239 (more than 30 minutes) are to be used to report the total duration of time spent by a physician for final hospital discharge of a patient. These 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 caregivers; and preparation of discharge records, prescriptions and referral forms.
When reporting procedure codes 99238 or 99239, the medical record documentation should specify the amount of time involved in completing the patient’s hospital discharge day management. If a physician bills the higher level of discharge day management, procedure code 99239, the total time spent rendering this service must be documented in the patient’s medical record indicating more than 30 minutes. If procedure code 99239 is billed and no time is documented in the patient’s medical record, Highmark Medicare Services may reduce the service to the lower level of care, procedure code 99238.
Initial Hospital Care and Discharge on Same Day
When the patient is admitted to inpatient hospital care for less than 8 hours on the same date, then Initial Hospital Care, from CPT code range 99221 – 99223, shall be reported by the physician. The Hospital Discharge Day Management service, CPT codes 99238 or 99239, shall not be reported for this scenario.
When a patient is admitted to inpatient initial hospital care and then discharged on a different calendar date, the physician shall report an Initial Hospital Care from CPT code range 99221 – 99223 and a Hospital Discharge Day Management service, CPT code 99238 or 99239.
When a patient has been admitted to inpatient hospital care for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date, Observation or Inpatient Hospital Care Services (Including Admission and Discharge Services), from CPT code range 99234 – 99236, shall be reported.