Corporate Compliance

Note from Hugh

Medicare Insider, January 15, 2008

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One issue that never seems to go away is the question of whether it is appropriate for a hospital to bill Medicare for an emergency department visit when a self-referred Medicare patient is triaged, but leaves before being seen by a physician. 

I last wrote about this issue in the May 3, 2007 Medicare Weekly Update. At that time, I reported on a discussion I had recently had with a CMS representative regarding this issue. Although not entirely clear, the CMS representative implied at the time that the answer to this question depends on how the local fiscal intermediary (or MAC) interprets the "incident to" rules. She indicated that hospitals should consult with their local FI or MAC for guidance on this issue.

For what it's worth, I can't see how such a visit would qualify for "incident to" coverage given that "incident to" coverage requires that the service "be furnished on a physician's order" and that "during any course of treatment rendered by auxiliary personnel, the physician must personally see the patient periodically and sufficiently often to assess the course of treatment and the patient's progress and, where necessary, to change the treatment regimen." See Medicare Benefit Policy Manual, Chapter 6 § 20.4.1.

Interestingly, however, last week my colleague Bill Malm (the Practice Director of HCPro's Revenue Cycle Management consulting practice) informed me that there is a 2005 bulletin in the archives on the Noridian Medicare Web site that contains the following Q&A (on p. 18):

    QUESTION 1: Can a hospital bill an Emergency Room (ER) visit when the patient leaves the ER before they see the physician?
    ANSWER: YES. Under OPPS the hospital may bill Medicare for the ancillary services they provide to the patient. Capturing nursing services when there is not a physician encounter and the nurse has performed triage in the ER is allowed. (Last reviewed 7/20/2005)

Unfortunately, the bulletin does not provide any analysis or explain how Noridian reconciles its answer with the "incident to" conditions of coverage set forth in the Medicare Benefit Policy Manual.

It is not clear whether the 2005 bulletin still reflects Noridian's policy. If it does, then a logical follow-up question is "Can hospitals in one of Noridian's jurisdications bill for "triage only" visits in reliance on the bulletin even if the guidance provided in the bulletin is inconsistent with CMS's Medicare Benefit Policy Manual?"

It seems to me that, at a minimum, hospitals in one of Noridian's jurisdications that intend to bill Medicare for "triage only" visits should check with Noridian to confirm that the 2005 bulletin still reflects Noridian's current policy on this issue. Those hospitals may also want to consult their legal counsel for an opinion on whether hospitals can rely on the bulletin if the guidance provided in the bulletin is inconsistent with the Medicare Benefit Policy Manual.




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