Does time need to be documented in order to submit for a hospital or nursing facility discharge service?

Yes, the time must be documented in the medical record to support the level of service billed for CPT codes 99238, 99239, 99315 and 99316.

Example: CPT code 99239 is used for a hospital discharge more than 30 minutes. Therefore, the discharge note would state, "45 minutes spent performing discharge services."


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