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

Yes. Hospital and nursing facility discharge services are time-based codes utilized to show the total duration of time that a physician or qualified health professional spent to discharge a patient. Time must be documented in the patient’s medical record to support the level of service billed.

Example: CPT code 99239 is billed. The patient’s discharge notes states “45 minutes of time spent performing discharge services”. The documentation supports the provider billing CPT code 99239 as more than 30 minutes of hospital discharge time is reported.
Hospital Discharge Codes

CPT Code
Code Description
Hospital discharge day management, 30 minutes or less
Hospital discharge day management, more than 30 minutes

Nursing Facility Discharge Codes

CPT Code
Code Description
Nursing facility discharge management; 30 minutes or less
Nursing facility discharge management; more than 30 minutes

Resources: CMS Medicare Claims Processing Manual (Pub. 100-04), Chapter 12, Section 100.1.4 (PDF, 1.5 MB)

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