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discharge or ?

  1. Default discharge or ?
    Medical Coding Books
    I'm reading a discharge summary from one of my drs and I get to the end and it says the pt signed himself out against medical advice. I don't know if I can really bill for a 99238 since the pt signed himself out. Help with this one please.



  2. #2
    Seacoast- Dover New Hampshire
    Did the Dr. have a face to face before the pt left? We had a pt leave ama but the MD did see him and advised how critical his condition was and what could happen if the treatment was stopped, and pt still left. I did bill for it as the MD dictated the note.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  3. Default
    Yes there was face to face time. I wasn't sure about the discharge code because we didn't discharge him. So didn't know what to do or if I could code a 99231-99233.


  4. #4
    Does your documentation mention anything with regard to the risks of leaving AMA and that the patient decided to leave anyway? In my view, that would support a discharge (not because the MD felt the patient is ready for discharge, but because the patient wants to go). If the provider mentioned the time and it was more than 30 minutes it might even be a 99239.

  5. Default
    My documentation has the final dx, reason for hospitalization and hospital course. No times as none of my drs ever dictate time for discharges. It states the "pt did not wish to stay in the hospital and did proceed to sign himself out against medical advice. Discussion was carried out with him in regards to pursuing a small bowel follow through as an op and following up with us as an op at the time of release. No discharge instructions because the pt did sign himself out AMA"

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