Gemini18
Expert
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.
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.