What CPT codes are used for discharge day management?

Use 99238 for discharge day management 30 minutes or less, or 99239 for more than 30 minutes. These codes cover final examination, discharge instructions, medication reconciliation, and coordination of follow-up care. Time includes face-to-face time on the discharge date.

What must be included in a discharge summary for CMS compliance?

CMS requires: reason for hospitalization, significant findings, procedures performed, discharge diagnoses, discharge condition, discharge medications with instructions, dietary and activity instructions, follow-up appointments, pending test results and who will follow up, and patient education provided.

When must the discharge summary be completed?

The discharge summary should be completed within 24-48 hours of discharge for continuity of care. Joint Commission requires completion within 30 days of discharge. For patients transferred to another facility, the summary must accompany the patient or be transmitted promptly.

How should pending test results be documented at discharge?

Document all pending labs, imaging, or pathology results. Specify who is responsible for follow-up (hospitalist, PCP, specialist) and how results will be communicated to the patient. Include instructions for the patient on when and how they will receive results.

What medication reconciliation is required at discharge?

Compare admission medications to discharge medications. For each medication, indicate: continued unchanged, dose adjusted, discontinued (with reason), or newly prescribed. Include indication, dose, frequency, and duration for all discharge medications. Document patient/caregiver education on medication changes.

Hospital Discharge Summary Template - Inpatient Discharge Note

Internal Medicine — Hospital Discharge Summary Template

Internal Medicine Hospital Medicine Updated: 11/7/2025

The Hospital Discharge Summary Template is designed for hospitalists, internal medicine physicians, and medical residents completing discharge documentation for patients leaving the hospital. This comprehensive template meets CMS and Joint Commission requirements for discharge summaries, systematically documenting the admission course, hospital stay events, final diagnoses, discharge medications, follow-up instructions, and care transitions. The template ensures continuity of care by providing primary care providers and specialists with complete information about the hospitalization, supports accurate billing and coding, facilitates care transitions, and reduces readmission risk through clear discharge planning. Key sections include admission and discharge dates, admitting and discharge diagnoses with ICD-10 codes, brief hospital course with significant events and procedures, final assessment and problem list, discharge medications with dosages and instructions, discharge instructions including activity restrictions and diet, follow-up appointments scheduled, pending test results and who will follow up, patient education provided, and contact information for questions. This template supports quality care transitions and reduces communication gaps between hospital and outpatient providers. Ideal for hospitalist programs, internal medicine services, academic medical centers, and community hospitals ensuring quality discharge documentation.

Discharge Information

Patient name, MRN, DOB
Admission date: [Date]
Discharge date: [Date]
Length of stay: [X] days
Discharging service: [Service/Team]
Discharge disposition: Home / SNF / Rehab / Home with services / Other: [specify]

Admitting Diagnosis

[Primary admitting diagnosis]

Discharge Diagnoses

1) [Primary diagnosis] — [ICD-10 code]
2) [Secondary diagnosis] — [ICD-10 code]
3) [Additional diagnoses as applicable]

Brief Hospital Course

Chronologic summary of hospital stay:

Day 1: [Admission events, initial assessment, treatments]
Day 2-3: [Significant events, procedures, consultations]
Day 4+: [Continued course, improvements, discharge planning]

Procedures Performed

[List procedures with dates if applicable]

Consultations

[Specialty consultations obtained and recommendations]

Discharge Medications

[List all medications with dosages, frequencies, and instructions]

[Medication name] [dose] [frequency] — [Indication]
Continue / Start / Discontinue [as applicable]

Discharge Instructions

Activity: [Restrictions, limitations, gradual return to activity]
Diet: [Dietary restrictions or recommendations]
Wound care: [If applicable]
Monitoring: [What to monitor, warning signs]

Follow-up Appointments

[Specialist/Provider]: [Date/time]
[Primary care]: [Date/time]
[Other]: [Date/time]

Pending Test Results

[Tests pending at discharge and who will follow up]

Patient Education

Topics discussed: [Medication adherence, warning signs, when to seek care, etc.]
Patient verbalized understanding: Yes / No

Discharge Condition

Stable for discharge / Improved / Condition improved but requires ongoing care.

Contact Information

For questions or concerns: [Contact information]
Return to ED if: [Specific warning signs]