# Discharge Documentation



## jdibble (Sep 9, 2011)

I have been trying to find what documentation is required in a Discharge Summary and have been not getting any straight answers.  I audit charts for documentation and education for our Hospitalists and some of my co-workers are sending charts back to the doctors with errors for Discharge summaries and downcoding them to Subsequent visits because they lack documentation of an Exam.  So far all I have found is information stating that an Exam is not required to be documented - just a statement of the patient's health status at discharge is needed.  My supervisor is supposed to be sending me information saying that the exam is required to be documented, but I have not seen it yet. Does anyone have any solid information on what needs to be documented in a Discharge Summary?

All information would be greatly appreciated! 

Thanks,


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## jdibble (Sep 12, 2011)

*Asking again!*

Stepping this up hoping someone can answer this question for me!

Thanks,


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## FTessaBartels (Sep 12, 2011)

*Read CPT guidelines*

Read the CPT guidelines for Hospital Discharge Services (2011 CPT Professional Edition, page 16)
*The hospital dischrage .... The codes include, as appropriate, final examination of the patient ... *  (emphasis added by FTB)

Per the CPT guidelines, there is no specific requirement except for noting time spent.  If it's 30 minutes or less it's code 99238;  if it's 31 minutes or more it is coded 99239.

And - by the way - how does this supervisor think s/he can code a subsequent visit without any physical exam but not code a discharge without a physical exam? 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## CrysLednum (Sep 13, 2011)

I also am having this problem.   I use Deborah Grider's "Medical Auditor" book for guidance and in Chapter 4 she states:

"Discharge Services include the following elements:

Final Exam of the patient

Writing Rx and Referral Forms

Discussions of Hospital Stay even if the time is not continuous

Instructions for continuous care to the relevant caregiver

Preparing discharge records

Hope that helps.


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## jdibble (Sep 14, 2011)

Thanks for the info Tessa and CrysLednum.  My supervisor sent me what documentation she had, which was from Highmark Medicare and it basically states the same thing...as appropriate, a final examination...  So then the question is what does "as appropriate" mean?  

The charts that were sent back to the doctors for errors did not have a traditional physical documented, but did refer to the status of the patients condition at the time of discharge.  I provided her with documentation that I did find that says a quick notation of the patients present physical condition would be considered the physical but she has not responded on this.  I can't find anywhere to what extent the exam needs to be documented - that is my issue.  If the doctor states "patient's vitals are stable and their abdominal pain has resolved" wouldn't that be documentation of an exam? Since there is no requirements of the extent of an exam such as in the other E/M codes, I don't see how these Discharges were deemed errors and switched to Subsequent codes, which were changed based on the History and MDM elements.


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## MnTwins29 (Sep 16, 2011)

*Not from Joint Commission, but...*

this was a good summary of requirements in the DC Summary from Partners Health Care in Boston.   This is from training provided to providers and the lessons state that this is required documentation in the DC Summary.   

http://www.partnerstransitions.org/Home/Home/discharge-summary-tutorial/essential-elements

It does mention an exam, but not extensively.


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## jdibble (Sep 19, 2011)

Thanks Lance - that was very helpful.


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