CPT code 99238: Hospital discharge day management (≤ 30 minutes)

Learn more about how to use the CPT code 99238, the code for observation discharge services, its documentation requirements, and billing guidelines.

Use Code

What is the CPT 99238 code?

The CPT code 99236, by the American Medical Association, is the lower time tier code used for hospital inpatient or observation discharge day management services when the provider's time spent on the discharge day, including the evaluation and management (E/M), is 30 minutes or less.

The service is provided by the attending physician or a qualified non-physician practitioner and generally includes:

Final evaluation
Patient instructions
Discharge documentation
Prescriptions, coordination of care, and face-to-face time spent with the patient, family, or caregivers.

An important thing to note about the code is that it cannot be used for the same calendar date for admissions and discharges. Should this be the case, it's best that one look for other observation codes and select which one is the most appropriate.

CPT code 99238 documentation requirements

Required documentation to properly use the CPT code 99238 must include:

Date of discharge and total time spent: The date of service should be the actual date of the face-to-face encounter, and as good practice, the specific time spent should be documented as well.
Medical necessity and details of encounter: The summary of hospital stay, as well as the medical necessity of the observation services provided from inpatient status and discharge, must be clearly stated in the documents.
Discharge instructions and records: Discharge instructions and records, including forms and prescriptions, if applicable, should be included in the patient's medical records.

CPT code 99238 billing guidelines

To increase the chances of proper reimbursement and billing, healthcare professionals using the code must keep note of the guidelines below:

99238 is billable once per hospitalization or hospital admission and only by the physician discharging the patient.
Time spent must be documented explicitly to distinguish between 99238 and 99239. Do not report both codes on the same day.

Frequently asked questions

No, only one provider—typically the attending—may bill for hospital discharge services per patient per day.

Yes, the physician must personally spend time with the patient on the same date of discharge or, at the very least, the discharge visit, even if the discharge itself is on a different calendar date.

Use the discharge code CPT 99239 instead, which requires documentation of time greater than 30 minutes.