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Discharge Summaries

  1. Default Discharge Summaries
    Medical Coding Books
    Can anyone help me with what a discharge summary HAS to have? All of my research has told me what SHOULD be in there, or what the pt's PCP and other Dr's would LIKE in there-but what absolutely has to be in there at the minimum?

    Amanda, CPC
    Urology coder

  2. #2
    Default
    I have wondered the same thing. In the CPT book it says "as appropriate" there should be a discharge exam and hospital course. Obviously the time spent needs to be there. What does "as appropriate" mean?

  3. #3
    Location
    Baton Rouge
    Posts
    1,239
    Default
    Here is a link to an article about the requirements for discharge summaries; it includes a checklist for what should be included. Google "documentation requirements for discharge summaries" and there's probably quite a bit more info so that you can get it in writing for your providers.


    http://www.acphospitalist.org/archiv.../discharge.htm
    Meagan Strauss, CPC, CEMC
    Coding Coordinator
    The NeuroMedical Center
    Baton Rouge, LA

  4. Default
    Thank you Meagan. I did actually see that link while I was researching this topic. It is a very good link for like I was saying above, i.e., what would be good and beneficial to be documented, but still can't find what exactly at minimum HAS to be in there. Like we have with the regular E/M guidelines...(need 2 out of 3, detailed history, expanded exam, etc.) Haven't seen anything like that for D/C summaries. Maybe you don't have to really have anything other than the date of d/c and diagnosis and for the Dr. to say he/she's discharging the patient. (???)

    Amanda, CPC
    Urology coder

  5. #5
    Location
    Baton Rouge
    Posts
    1,239
    Default
    Here's 1 more...this 1 states what is "mandated", so i would think this would be the minimum requirements...



    http://www.ahrq.gov/downloads/pub/ad...es-Kind_31.pdf


    Meagan Strauss, CPC, CEMC
    Coding Coordinator
    The NeuroMedical Center
    Baton Rouge, LA

  6. Default
    Awesome! Thank you! I'll have to look more up about 'Joint Commission' and if they go by Medicare or what. But this is great!

    Amanda, CPC
    Urology coder

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