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Medicare reform update: EMTALA provision alters billing outcome

Compliance Monitor, February 4, 2004

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A new change to the Medicare reform bill (H.R.1-2003), which went into effect January 1, has a direct effect on emergency room (ER) procedures. According to an EMTALA provision, (Sec. 944, EMTALA improvements), hospitals may decide whether a study or service is medically necessary based on presenting symptoms or complaints, not on the patient's principal diagnosis. The claim's final outcome would still depend on other factors, such as documentation, but the medical record, if coded properly, can prove medical necessity based on initial symptoms.

During an ER visit, if a patient has a medical test done that doesn't meet the criteria for medical necessity, the hospital should still be reimbursed.

Yvette Marcan, data quality and outpatient payment coordinator at Holmes Regional Medical Center in Melbourne, FL, provided an example. If a patient comes into the ER with leg pain, and the ER doctors want to rule out thrombus, they order a lower extremity doppler study. If the patient does not have thrombus, under the old rule, the claim would be denied. Under the new provision, Medicare would reimburse the hospital for this claim.

Hospitals can now bill for these services as a regular covered test. There is no need to put them in the non-covered column, as many hospitals used to do, Marcan says.

Facilities may need to adjust these edits for ER cases and list items not meeting medical necessity as covered when the patient is seen in the ER, Marcan says. "At this time, I am unable to determine whether we continue to place items not meeting medical necessity in the non-covered section for ER claims," she says.

Compliance Monitor will keep an eye on developing implications of this provision. Experts acknowledge there are still unknowns, including specific coding guidelines.

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