Wiki Discharge Summary

[Ellis000]

Hello, I am a new coder and have some issues with Discharge summaries for Inpatient and Observation. If we have a doctor who documented a progress note and a discharge for the same day, we bill the Discharge, correct?
I thought this, but when I asked a provider to sign the documentation for the DC, he told me that he already signed the progress note and so the DC is not billable.
Does this mean we only bill the one the provider signed instead?

Thanks,

 

[Pathos]

Per CMS Claims Processing Manual Ch. 12.30.6.9.2

C. Subsequent Hospital Visit and Discharge Management on Same Day
Pay only the hospital discharge management code on the day of discharge (unless it is
also the day of admission, in which case, refer to §30.6.9.1 C for the policy on
Observation or Inpatient Care Services (Including Admission and Discharge Services
CPT Codes 99234 - 99236). A/B MACs (B) do not pay both a subsequent hospital visit
in addition to hospital discharge day management service on the same day by the same
physician. Instruct physicians that they may not bill for both a hospital visit and hospital
discharge management for the same date of service.

You got it right; the provider should sign for both encounters, but only the discharge is billable. As a rule of thumb for inpatient E/M billing, only one E/M code per day is billable.