I currently work for a Rural Health Clinic and our providers go over to the hospital and see patients in the Rural hospital. I currently took over coding these charges and have noticed there is no specific notes pertaining to when a PT is discharges from SNF ( inside the hospital). There is a Discharge sheet where they write the DX on there and sign. Is this adequate documentation to bill out a discharge such as 99315? Should there not be a final physical exam done or documentation that states discharge instructions for the PT?