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Discharge instructions guide patient care after leaving the hospital, covering medications, activity, diet, and follow-up appointments. Progress notes (A) document care during the stay. Nursing flowsheets (B) track vitals and interventions. Consultation notes (D) provide specialist recommendations. Coders may review discharge instructions for context but rely on discharge summaries for coding diagnoses.

The Resource-Based Relative Value Scale (RBRVS) assigns RVUs to CPT®/HCPCS services based on physician work, practice expense, and malpractice cost. MS-DRGs (A) apply to inpatient hospitals. OPPS (C) applies to outpatient. PDPM (D) applies to SNFs. Coders must understand RBRVS, as accurate CPT® coding ensures fair physician reimbursement.