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E/M for patient left hospital AMA?

  1. Default E/M for patient left hospital AMA?
    Medical Coding Books
    I am coding the professional fees for a Hospitalist group. Can anybody tell me if I can charge a discharge E/M for patients who leave the hospital AMA? In this case the provider did see the patient earlier in the day, but does not have any information regarding discharge instructions or plans in the progress note. Should I charge a subsequent visit or a discharge code? Please share any links that support your answer.

  2. #2
    Location
    Dover Seacoast New Hampshire
    Posts
    2,028
    Default
    You have to code based on the documentation at hand, not necessarily on what you think the situation is.

    If there is no discharge documentation (i.e. description of the hospital course, discharge planning, etc.) then you'd have to code based on what was discussed in the visit earlier in the day, as long as medical necessity is met and there is a complaint, and documentation to support an inpatient subsequent visit.
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  3. Default
    Thanks Pam!

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