tci E/M Coding Alert - 2013 Issue 5

Reader Question: Stress Time Documentation Requirement for Discharge Coding

Question: The doctor admitted a patient and then discharged the patient five days later. Before discharging the patient from the hospital, the same 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? Hawaii Subscriber Answer: You may report 99239 (Hospital discharge day management; more than 30 minutes) provided your provider’s documentation indicates the floor time (the time the physician spent preparing and dictating the discharge summary) and what the physician did. E/M guidelines indicate that you should use 99239 “to...

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