E/M - Discharge documentation Question

carole0403

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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?
 

maudys

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if you have a discharge order on the same day outlining the discharge plan which correlates with the discharge note, i would say stating "discharge" in the note is irrelevent, but definitely needs to be noted in the orders for that day. the discharge orders have to include the patient's disposition, so that should suffice.
 
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