Don't have a TCI SuperCoder account yet? Become a Member >>

Regular Price: $24.95

Ask An Expert Starting at $24.95
Have a medical coding or compliance question? Don’t sacrifice your valuable time to endless research. Choose Ask an Expert to get clear answers from the TCI SuperCoder team. And here’s a tip for the budget-conscious: Select the 12-question pack to get the best rate per question!

Browse Past Questions By Specialty

+View all

Admint and Discharge same day documentation requirements

Melissa Posted Thu 19th of January, 2017 14:39:17 PM
Do you need a (2) reports one for admit and one for discharge for the following codes: Admit and Discharge on Same Day (In-Patient AND Observation) 99234, 99235, 99236 What are the documentation requirements?
SuperCoder Answered Fri 20th of January, 2017 04:58:16 AM

There is no specific need for separate record for discharge service. Physician can mentioned on the same record about admit and discharge of the patient with proper notation, like; it should mentioned total duration of time spent for final hospital discharge. The discharge code include final examination of the patient, discussion of the hospital stay, even if the time spent by the physician on that date is not continuous, instructions for continuing care to all relevant caregivers, and preparation of discharge records, preparations and referral forms. This can be notified as “Discharge Note”, which is sufficient for the billing.

Related Topics