99238
Hospital discharge day <= 30 min
Hospital inpatient or observation discharge day management, 30 minutes or less. CMS 2026 wRVU 1.50. The lower-effort of the two discharge codes; appropriate when discharge documentation, med reconciliation, and patient instructions can be completed in under 30 minutes.
When to use it
Use 99238 for routine discharges where total discharge-day work is 30 minutes or less.
Full guidance
Examples: discharge from a 1-2 day admission for IV antibiotics with a stable course, discharge after observation rule-out with no significant prescription changes, post-op discharge on day 1 with a routine pathway.
Documentation checklist
- ✓Discharge summary or discharge note documenting hospital course, discharge diagnoses, condition at discharge, and disposition.
- ✓Medication reconciliation completed and documented.
- ✓Discharge instructions provided and documented (verbal or written).
- ✓Follow-up plan with PCP or specialist.
- ✓Time spent on discharge-day activities: under 30 minutes for 99238, over 30 minutes for 99239.
Common pitfalls
- !Documenting elaborate discharge work and then billing 99238 instead of 99239. If time exceeded 30 minutes, code 99239.
- !Forgetting medication reconciliation documentation. Required for both 99238 and 99239 billing.
- !Billing 99232 plus 99238 for the same calendar day; only the discharge code is billable on the discharge date.
Payer notes
Medicare and commercial payers pay 99238 at the standard PFS allowable. Some payers require documentation of the time spent on discharge-day activities to support the 99239 (over 30 min) code; documentation should include the total time and qualifying activities (med rec, family discussion, PCP communication, prescription writing).