Wiki E/M for patient left hospital AMA?

[Lissarae]

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.

 

[Pam Warren]

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.

 

[Lissarae]

Thanks Pam!