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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Medicare Discharge Summary FAQs

See our Discharge Summary section for more guidance.

Is a discharge summary required for every patient?

Yes. 

What if the patient just stops coming to therapy?

In the case of an unanticipated discharge, the clinician may base any judgments required to write the report on the treatment notes and verbal reports of the assistant or qualified auxiliary personnel.

What is required on the discharge summary?

The discharge note shall be a progress report written by a clinician, and shall cover the reporting period from the last progress report to the date of discharge.

References

Medicare Benefit Policy Manual Ch. 15 – Covered Medical and Other Health Services § 220.3

Billing and Coding: Outpatient Physical and Occupational Therapy Services: A57067

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