How To Bill AMA Discharge (Against Medical Advice) In the Hospital

I've had a lot of folks find The Happy Hospitalist using the search string "How to bill AMA discharge".  So I figure, what the heck, I might as well devote an entire post to help thousands of hospitalists know how to bill this common situation.  Us hospitalists deal with this every day.  

"You will be leaving against medical advice" is what patients will be told if the want to leave the hospital against the advice of their physician.  Often, the nurses will have the patient sign a form for AMA discharge.  I have no idea what the form says or what  its purpose is  in a court of law.

Many doctors and nurses falsely believe that their responsibility for safe patient discharge ends as soon as a patient makes a decision not continue their stay in a hospital against the advice of their medical team and signs that mystery form. They couldn't be more wrong.  The physician's (and nurse's) responsibility for patients wishing to leave against the advice of their team is actually more intensive for the AMA discharge.

As a resident physician I was taught patients who wished to leave AMA were to leave empty handed.  No scripts.  No follow up.  No nothing.  If they wanted to leave against our wishes then we were protected from any bad outcomes and we were not obligated to formally discharge them. 

How and why this was taught to us is beyond me.  As physicians, we have an obligation to provide as safe a discharge plan as we can, even if a patient wants to leave against our medical advice.  If patients state they want to leave AMA, we have an obligation to determine if the patient has the capacity to make that decision, and if so, then we have an obligation to inform them of the risks and dangers of leaving against our medical advice.  And once they have been fully consented , by us, on the risks and benefits of leaving, we have an obligation to order all necessary follow up cares, whether that be medications, xrays, labs or follow up appointments.  

If you think about the AMA discharge rationally, patients who voluntarily agree to be admitted to the hospital also have the option of voluntarily leaving.  Hospitals are not prison wards.    We cannot force patients to stay in the hospital (or even on their own floor if they wish to go outside for a cigarette).  If they choose to leave at any time during their stay and we can document they have the capacity to make poor medical decisions, no matter how poor they are, we cannot prevent them from leaving. They have a right to leave anytime.

But what about patients that won't stay long enough to complete the discharge paperwork?  What do we do about them?  Here's how I handle that situation.  If I feel the patient lacks the capacity to make the decision to leave the hospital, and they want to leave anyway, if I have time to act, I will ask psychiatry to evaluate the patient for a potential emergency protective custody order.  If that process cannot be implemented fast enough and the patient walks out the door of the hospital, I have the floor call the police to pick up the patient and let them decide if they want to file an emergency protective custody order and bring them back to the hospital.  I cannot physically restrain a patient, who arrived voluntarily, from leaving voluntarily against our advice, without an EPC.   That would be kidnapping.  Law enforcement must decide. 

 The vast majority of time patients who lack the capacity to make decisions don't try to  leave the hospital AMA, so that's a very rare situation.   If I feel the patient is capable of making their own decision to leave, they can leave at any time.  If they leave before the formal discharge recommendations can be made (prescriptions, appointments, follow up lab and radiology needs), I simply document that the patient would not agree to wait for the formal discharge recommendations.  If the patient leaves before I can make a bedside or  phone call confirmation of their capacity to make their  own  decisions, then I document that I was not able to interview the patient before they left.  I attempt to ascertain if the rest of the nursing team felt the patient was a danger to themselves or others.  If so, I ask them to call the police to interview the patient and determine if they need to file an EPC.

So how should physicians bill AMA discharges?  We bill them exactly how we bill all other hospital discharges.  If you already saw the patient earlier in the day, you use that amount of time, in combination with your bed side medical capacity evaluation to determine if you bill the more than 30 minutes or the 30 minutes or less discharge  codes 99239 and 99338.  If the patient is an observation patient, you bill the observation discharge code 99217 just as you would any other patient.  If the patient left before you could do a face to face evaluation, I document that I attempted to provide a face-to-face visit, but that the patient would not remain in the hospital long enough and then I complete a discharge summary  and any relevant orders, if indicated, and I bill the appropriate level of discharge for inpatient or observation stay.  

If you are a patient, you're probably wondering if insurance will pay for your hospital stay if you leave AMA.  If you are Medicare or Medicaid, the answer is yes.  Insurance will pay.  All care that was determined to be medically necessary is paid for.  If you choose to leave against our medical advice, that's your right.   You also have the right to demand that your doctors and nurses formally discharge you with all necessary orders for necessary medications, follow up laboratory, radiology needs and follow up appointments.

 If you have private insurance, my hunch is that they will pay, however, you should check with your policy to make sure it does not contain a clause that says they will not pay if you choose to leave against doctor's advice.  To be honest, though, I'm not sure how any insurance company could get away with not paying for care if you choose not to accept continued care from your medical team.  That would go against the patient's right of refusal of care.  You have every right, at all times, of refusing any and all cares you are offered.  

Make sure to review my free E/M coding lectures and my hospitalist resource center filled with valuable information on practice management.  


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