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Note from Hugh

Medicare Weekly Update, April 24, 2007

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Questions have recently been raised about whether there any circumstances under which Medicare would cover a facility emergency department encounter where a patient is seen by a hospital nurse, but leaves before being seen by a physician. It seems to me that these types of encounters would not meet Medicare's "incident to" coverage criteria because the services were not furnished "incident to" the services of physician as required under 42 CFR 410.27. However, several people have suggested that many hospitals bill Medicare for these types of encounters and that they must somehow be covered by Medicare.

In follow-up, I posed this question to CMS during the April 19 Hospital Open Door Forum. No one from CMS was able to answer the question on the call. However, the moderator of the call took my phone number and said that someone from CMS would get back to me.

If I am able to obtain any further clarification from CMS, I will include it in a future version of this newsletter. In the meantime, hospitals that are billing Medicare for emergency department encounters where a patient is seen by a hospital nurse, but leaves before being seen by a physician, should give serious consideration to whether that is really appropriate.

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