Wiki Discharge Summary

[LStana]

I am trying to find out what day we would actually bill a discharge summary. I have a scenario where one physician dictated part of a discharge summary on 4/2/14 and another physician dictated an addendum on 4/9/14 and completed the discharge. This is not a case where any labs came back abnormal or waiting for a nursing facility. The physician just wanted to get a head start on the discharge. Should they be doing this? And, what date do we bill the discharge summary? Thank you for your help.

 

[Pam Warren]

The discharge summary should be dated and documented as of the day that the discharge assessment is done on the patient. It's preferable that it is the same day that the patient leaves the facility. We do know that sometimes patients get held overnight due to unforseen issues, but this should not be the norm (such as if lab findings are needed before a discharge takes place, then the patient should not leave until the labs are resulted). There shouldn't be a D/C summary done days prior to the actual date of discharge, however.
Here's how our payer has instructed us to bill for delayed discharges: If the D/C summary is done on Tuesday, and an addendum done on Wednesday just before the patient actually leaves, we bill the discharge for Tuesday, and if there's enough documentation/support/medical necessity in the Wednesday note, we have billed a round for Wedesday. If not, we bill nothing but the d/c on Tuesday. If the D/C summary is done Tuesday, and the patient remains in the hosptial for several more days, that D/C is billed as a round, and the provider has to do another D/C summary on the actual date of discharge. Payers may vary on how they want this scenario handled, so it makes sense to check out your carrier's E&M billing guidelines.

 

[LStana]

Thank you so much for your response.