Discharge E/M


True Blue
Best answers
Do I code a discharge code when the progress note states.

Discharged. 7/26/08
Transferred to another hospital for angiogram.
Discharges normally include a 'summary' or 'clinical resume' of the inpatient stay - Discharge codes (99238 or 99239) are time based codes only. If no time is documented greater than 30 minutes (99239) it would be appropriate to bill 99238 (30 minutes or less)
DC Management NOT documented

Here's what CPT says about Hospital Discharge Services (from 2008 CPT Professional edition, pg 14-15:
The hospital discharge day management codes are to be used to report the total duration of time spent by a physician for final hospital discharge of a patient. The 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.

All I see in your doctor's "documentation" is a statement that the patient was discharged. I don't see any evidence that it was this physician who actually performed the discharge day management.

I would NOT code this if that's all there is to the "progress" note.

F Tessa Bartels, CPC, CPC-E/M