Wiki Leaving AMA

[Jacoder]

I code for the Emergency Room at our hospital, facility and physician. From time to time we will have patients recieve care and then leave against medical advice. One of our doctors doesn't like to give diagnosis for these pateints because he claims he didn't get to finish the care needed to provide a diagnosis. He completed all three components of the evaluation and management, but without a diagnosis we can't bill for this. In his defence I can see where he is coming from, but I don't know the correct way to go about this. If the patient leaves AMA can we code from signs and symptoms stated in the cheif complaint? Do we have to have the Dr complete the diagnostic section of the eval?

Thanks!

 

[Jacoder]

I think I just found the answer to my own question. (I knew I should have researched farther!) The coding guiedlines state "Codes that describe symptoms and signs, as opposed to diagnoses, are accepted for reporting purposes when a relative definitive diagnosis has not been established (confirmed) by the provider."

I think this means I can use the S&S for leaving AMA. Anyone disagree?

 

[Mojo]

I agree with you. I have used the chief complaint, the HPI (increased specificity) and the exam for the signs (the provider's objective findings).