How do you code a discharge summary?

There are two CPT codes to choose from for these services “99238 and 99239 “and the difference between them comes down to time. If the entire discharge, including all preparation, takes 30 minutes or less, you need to report 99238. If, on the other hand, the process takes more than 30 minutes, you should report 99239.

What is included in a discharge summary?

These questions included the 6 elements required by The Joint Commission for all discharge summaries (reason for hospitalization, significant findings, procedures and treatment provided, patient’s discharge condition, patient and family instructions, and attending physician’s signature)[9] as well as the 7 elements ( …

Is a discharge summary required?

Even though discharge summaries are not required by all companies, I highly recommended writing them even if you do not take insurance and only accept private pay clients. They are useful for the client and can protect you from legal action.

What is a discharge summary report?

A discharge summary is a clinical report prepared by a health professional at the conclusion of a hospital stay or series of treatments. It is often the primary mode of communication between the hospital care team and aftercare providers.

Can you bill for a discharge summary?

You may not bill for both the discharge service and the admission to the new facility if both of those services occur on the same calendar date. In general, physicians may bill (and be paid for) only one evaluation and management (E/M) service per specialty per patient per day.

Who is responsible for discharge summary?

Regardless of who documents the discharge, the attending physician is responsible for the content and quality of the summary and must sign and date it. The Joint Commission has established standards (Standard IM. 6.10, EP 7) outlining the components that each hospital discharge summary should contain.

Why is discharge summary important?

Physicians and other practitioners need to know details about the care a patient receives during an inpatient hospital stay. Discharge summaries are an invaluable resource that may improve patient outcomes by providing for continuity and coordination of care and a safe transition to other care settings and providers.

When should a discharge summary be completed?

Timely Completion of a Discharge Record Records should be assembled, analyzed, and completed within 30 days of discharge unless state law specifies another time frame. A record should be removed from the nursing station as soon as possible after discharge within 24 – 48 hours, but no more than 72 hours after discharge.

What is the purpose of the discharge summary report?

Hospital discharge summaries serve as the primary documents communicating a patient’s care plan to the post-hospital care team. Often, the discharge summary is the only form of communication that accompanies the patient to the next setting of care.

How do you bill same day admit and discharge?

A: Bill a CPT “Observation or Inpatient Care Services (Including Admission and Discharge Services)” code, 99234-99236. These codes are to be used for a same-date admission and discharge in the observation status or inpatient setting.

What is the purpose of a discharge summary?

Can a diagnosis be coded in a discharge summary?

A: As long as a diagnosis is documented in the record it can be coded. Discharge summary guidance only applies to suspected/probable diagnoses, for which the ICD-9-CM Official Guidelines for Coding and Reporting state the following: “If the diagnosis documented at the time of discharge is qualified as “probable”,…

Do you need to be documented in the discharge summary / final progress note?

Do they need to be documented in the discharge summary/final progress note, or can they be coded from an earlier progress note? A: The Official Guidelines for Coding and Reporting tells us that a diagnosis documented as being uncertain during an inpatient stay must remain so at the time of discharge.

Can a hospital disallow an ICD 9 cm discharge?

This does not prohibit, however, some Recovery Audit Contractors from violating ICD-9-CM rules and disallowing established diagnoses that are not in the discharge summary. Some hospitals in San Francisco are dealing with these issues.

Do you have to be in discharge summary?

Being in the discharge summary is not a requirement but different organizations are making up their own rules (such as RAC)”. Question: Please provide clarification regarding the appropriateness of code assignments based on the documentation in the medical record by a physician other than the attending physician.