AMA CPT® Assistant - 2011 Issue 7 (July)
Evaluation and Management Services (Q&A) (July 2011)
July 2011 page 16 Evaluation and Management Services 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...
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Article Overview
This article is a short Evaluation and Management Q&A from CPT Assistant that focuses on hospital discharge day management services and how the CPT guidelines address the components of discharge reporting. It is aimed at coders, billers, and compliance staff who need to understand the general scope of the guidance and its relevance to hospital discharge documentation.
Why This Topic Matters
Hospital discharge reporting is a common E/M coding task, and understanding the applicable CPT guidance helps organizations align documentation and reporting practices with the codebook.
What You Will Learn
- The general CPT guidance discussed for hospital discharge day management services
- Which discharge-related elements are addressed in the article
- How the Q&A frames the reporting context for hospital discharge services
- The publication context and timeframe of the guidance
Who Should Read This
- Medical coders
- Hospital billers
- Coding compliance staff
- Physician documentation teams
Codes Discussed
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