Corporate Compliance

Note from Hugh

Medicare Insider, May 1, 2007

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Last week, I wrote that I had asked CMS on the April Hospital Open Door Forum call whether there are 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. Shortly after the call, a CMS representative contacted me by phone. She explained that my question requires interpretation of the regulation (presumably 42 CFR § 410.27) and that the CMS manual provision on "incident to" coverage (presumably, she was referring to the Medicare Benefit Policy Manual, Chapter 6 § 20.4.1) does not clearly address my question. She informed me that hospitals should obtain guidance on this issue from their individual contractor (i.e., fiscal intermediary or Medicare administrative contractor). Although CMS did directly answer my question, it appears that hospitals should not bill Medicare for an emergency department encounter where a patient is seen by a hospital nurse, but leaves before being seen by a physician, unless approved by the applicable FI or MAC.



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