Wiki Missing Discharge Summary

jademound

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Mobridge, SD
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I have a patient that was admitted for end of life care. I am aware of the rules that come with that for the bed charges, etc but I have some questions about other things.
1) Patient had toenails trimmed by nursing - this is included in what would be considered bed charges, correct?
2) Patient had toenails trimmed by physician - can I bill 11719? (G0127 does not apply)
3) Patient had foley cath replaced twice during stay by nursing staff - is this included in what would be considered bed charges?
4) I'm embarrassed for my facility to even ask this question... The provider did not complete a discharge summary. The patient passed on 9/22 and I am asking this on 11/25. Is there anything I can do? Also, am I able to include any diagnosis codes besides what is in the H&P then? There were several dx codes that I would normally be coding if there was a D/C summary present. The patient passed from Metastatic Cervical Cancer to the Brain and Liver.

What do I do with this. It is rather urgent that I get this addressed, as it has already been 2 months since the patient expired.
 
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