Does the physician have to actually state that s/he is discharging a patient in the chart note to be able to bill for a discharge? Or, can a discharge be billed if all of the CSM documentation standards have been met without actually noting the patient is being discharged. This is for CPT 99238 and 99239. I can't find ANYTHING written that requires "discharge" to actually be stated in the medical record. Can anyone direct me to anything in writing?