• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki Discharge E/M

Create Wiki
D

daniel

True Blue
Messages
865
Location
Fontana, CA
Best answers
0
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
 
You must log in or register to reply here.
Top