This 83-year-old has been a resident for the past 1.5 years. She was admitted because she had polio with left hemiparesis and a speech impediment. She was hospitalized four months ago with an exacerbation of COPD, dehydration, and low blood pressure. After physical, speech, and occupational therapy, the patient has now become more independent and is able to walk behind her wheelchair. She is able to perform all of her activities of daily living (ADLs). Routine lab work was completed last week and was found to be within normal ranges. The patient is being discharged to her daughter’s home.

Final Examination of Patient:
- The patient is alert. Vital signs: BP 120/66, P-64, R-12, weight – 165 lb.
- HEENT: Head—normocephalic.
- EENT: Clear.
- Neck: No lymphadenopathy or thyromegaly.
- Lungs: Clear, good air entry.
- Heart: Regular rhythm, no murmurs. Distal pulses palpable.
- Abdomen: Soft, nondistended.
- Neurological: Cranial nerves 2–12 grossly intact except for speech impediment. Has left hemiparesis.

Discharge records were completed, and instructions and prescriptions were given to the patient’s daughter.

a. CPT code: _________________

To determine the correct CPT (Current Procedural Terminology) code, we identify the primary service provided to the patient. Given the context, it seems the most relevant code would be for a discharge management service, as the documentation describes a final examination and discharge plan.

For hospital discharge services, the CPT codes are:

99238: Hospital discharge day management; 30 minutes or less.

99239: Hospital discharge day management; more than 30 minutes.

Since the duration of the discharge management isn't specified, we generally assume the lower time unless otherwise indicated.

Therefore, the CPT code for the discharge day management service provided to the patient would be 99238.