CPT 99238.99239 documentation requirments

Does a physician have to document in the chart that s/he is "discharing" the patient to be able to bill 99238/39 or, can these codes be billed without mention of "discharge" in the chart notes so long as all CMS documentation requirements are met? I can't find ANYTHING in writing.

Discharge

These 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 care to all relevant caregivers; and preparation of discharge records, prescriptions and referral forms. The actual word "discharge" does not have to be there because the CPT code states the service rendered, but it doesn't hurt.

When reporting procedure codes 99238 or 99239, the medical record documentation should specify the amount of time involved in completing the patient’s hospital discharge day management. If a physician bills the higher level of discharge day management, procedure code 99239, the total time spent rendering this service must be documented in the patient’s medical record indicating more than 30 minutes. If procedure code 99239 is billed and no time is documented in the patient’s medical record, Medicare may reduce the service to the lower level of care, procedure code 99238.

Discharge

Nancy has given the CPT definition of discharge. I believe it includes the words, on the last day of the hospital stay.

Only one MD can perform and bill for discharge/admission.

I would expect to see the doctor's orders to say "Discharge today," or else the patient couldn't be discharged. Also, the progress note usually has a brief summary, and then notes that a discharge report was dictated. The hospital will bug the doctor until that is dictated. Get a copy of the orders for the date, the progress note, and the discharge summary.

Is there a specific instance that you have in front of you?

Discharge documentation

No, this is a general question. I am unable to find anything in writing that states that the chart note must state that the patient is being discharged or that it doesn't need to be stated.

I appreciate your reply!