Best Practices for Handling AMA Discharges and Coding Accuracy
By Tiffany Ferguson, LMSW, CMAC, ACM
When a patient leaves the hospital against medical advice (AMA), the discharge is not only a clinical concern, but it can also create coding and compliance challenges. Ensuring the process is clear, consistent, and patient-centered helps protect both patients and providers while supporting accurate coding and revenue cycle integrity.
It should be very clear, as discussed in a Dr. Ronald Hirsch 2021 article on “Leaving Against Medical Advice” that an AMA discharge does not mean that the patient is non-compliant or that the discharge now becomes adversarial. In fact, the care team should still support the patient in their discharge needs with needed prescriptions, any follow up arrangements, and coordination of care needs to balance the patient’s wishes with the physician’s concerns.
In reviewing existing AMA processes, many organizations utilize a process in which the physician and patient identify that the patient’s requested discharging location or desire to leave the hospital is not clinically safe, nursing will provide the patient with an AMA form to be signed. This vital form provides some protection for the hospital and the attending should the patient have an adverse outcome after they decide to leave the hospital, while still preserving the patient’s right to self-determination.
There are other methods to this process, such as incorporating the AMA designation directly into the discharge order. Regardless of the method, however, it must be very clear from a coding and billing standpoint that to ensure the correct discharge, that the status code to be applied. The Patient Discharge Status Code is “07” (Left against medical advice or discontinued care).
The language used in AMA forms is just as important as the documentation itself. Forms should strike a balance between acknowledging patient autonomy and reflecting the care team’s professional recommendations.
For example, rather than presenting the form in a punitive tone, hospitals should consider patient-centered language:
“Your care team only wants the best for you; however, we respect your right to self-determination. This form acknowledges that while your care team recommended discharge to [facility/plan], you have chosen to discharge to [alternative plan].”
This tone emphasizes respect for patient rights while making it clear that the team has offered appropriate guidance. Hospital Patient Advocates and Risk Management teams can be valuable partners in revising these forms.
What Happens if the Patient Returns?
A common concern is whether anything additional is required if a patient who left AMA returns through the emergency department. In short, no new documentation is needed beyond the usual admission process. Coding does not require a unique flag or code for these accounts on readmission. From a readmission penalty perspective these cases are excluded. However, from a medical necessity and utilization standpoint, acknowledgement of these patients for internal review is still meaningful.
That said, some electronic health record (EHR) systems provide valuable tools. For example, in Epic, the ED tracking board’s “Boomerang” rule identifies all readmissions within a certain time frame. This initiative allows ED UM and CM/SWs to review repeat visits and determine whether the patient truly requires hospital level services for admission or if a different intervention could better address their needs.
From a utilization management perspective, the key question is whether the patient’s return visit meets medical necessity criteria for observation services or inpatient status, regardless of their prior AMA. While the AMA history may inform the clinical discussion, it should not alter the application of CMS guidelines.
Hospitals may find it particularly useful to monitor these cases when AMA discharges involve recommendations for post-acute settings (such as inpatient rehab, SNF, or LTC).
Patients who decline such care and return within 24–48 hours may highlight both quality-of-care and readmission risk issues. This may support the balance for internal quality audits to examine, the question- ‘why are patients not following the care team’s advice?” is it really rugged individualism or is something missing in the transitional process with either over recommendations to post-acute placement or recommendations to poorly rated post-acute placements leaving patients fearful to go and electing home instead.
AMA discharges will always carry clinical, ethical, and operational complexity. However, with clear documentation processes, and patient-centered language, that supports coding visibility and subsequent use of Discharge Code 07, hospitals can reduce risk of erroneous readmissions as well as penalties from CMS and payers.
This process will alleviate hospital risk if the patient requests to discharge to an ‘unsafe’ location or prior to care being complete.