Hospital discharge summary documentation


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Can someone tell me if a physician must document a discharge summary to be able to charge for the discharge codes. The physician see a patient and does a E/M visit and document that and later on comes back on that day and decides to discharge the patient. They will write orders to discharge the patient, give the discharge diagnosis, diet to continue. There is a discharge med list that they check what meds the patient is to go home with. If there is any follow up appointments ,this is writen in the note. What they do not document is the course of the hospital stay, should we be charging the discharge codes if they do not document that. I have read the CPT guiedlines for the discharge codes and I believe that they need to do that. help
Last edited:
Milwaukee WI
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Time required

If the physician wants to bill 99239 time must be reported as 31 minutes or more.

The Discharge Summary is usually a requirement of the facility, and has no bearing on whether or not discharge day management was appropriately documented. (Though it does make our lives easier.)

Hope that helps.

F Tessa Bartels, CPC, CEMC