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No documentation

  1. #1
    Question No documentation
    Medical Coding Books
    I have a record I am auditing, it is for a inpatient discharge 99238.

    Physician did not do a discharge summary. I have his orders and progress note only. He noted on both of them "Transfer to cardio." Also, the patient was in the hospital for 2 days 7/19/09 - 7/21/09.

    What would you guys do with this record? I can't see myself giving him credit for this, because of no documentation.

  2. #2
    Milwaukee WI
    Default Patient stayed in two days more?
    I'm not sure I follow you .. did the patient remain in the hospital two additional days beyond the "discharge?"

    There are no specific guidelines for what needs to be included in discharge day management documentation - other than time, if over 30 minutes.

    So if your physician was the admitting physician, and still the attending physician on day of discharge, and there is a progress note for the date of discharge, and any indication that the patient will be discharged (orders count), you could code the 99238.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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