Apr 13th, 2015 - rrenninger
I am coding for the physician hospitalist services. Compliance wants the hospitalists to document a full progress note with the discharge criteria on it. The problem is the hospital has them document a discharge summary already so the physicians want to include the discharge info on the discharge summary so they do not have to have extra work to do. my question is: do the hospitalist need to have a progress note when they have a discharge summary? Compliance says our medicare contractor, WPS, says this is their requirement but when asked to compliance where in WPS policy does it state this she says it isn't a policy but a basic E/M guideline. Thank you, Randi
Apr 14th, 2015 - Codapedia Editor 1,399
re: discharge services
The discharge codes for physicians (99238, 99239) include all of the work on the day of discharge, without specific history, exam and MDM requirements. There isn't a CPT® or CMS rule about the format of that discharge summary. Should it be dictated, hand written etc. The hospital has rules for its licensure that requires a discharge summary. I'm not aware of any rule (which doesn't mean it doesn't exist) that requires two notes: a progress note and discharge summary.
When I hear this type of statement, I always say, "Thanks. I wasn't aware of that. Can you share the citation for it?" No citation, no cookies.