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Printed Date: 9/22/2015
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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Last Updated: 09/03/2019