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Special Bulletin

Medicare Weekly Update, May 3, 2007

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I am sending this special bulletin in follow up to the "Note from Hugh" published in the May 1 issue of the Medicare Weekly Update. That note was as follows:

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.

After the e-zine was published, a reader contacted me and questioned whether CMS' current position on this issue is different than CMS' position as described in a Q&A published on HCPro's Web site in 2005. That Q&A suggested that under some circumstances, hospitals could code and bill for triage-only visits. The Q&A was based on information CMS published on page 18452 of the April 7, 2000 Federal Register. That Federal Register article stated:

Comment: Several commenters advised that a screening code was not necessary because an emergency visit code could be billed for ED screening services.

Response: We agree with the commenters, and we will instead use the appropriate emergency department codes for screening services (as defined in section 1867(a) of the Act). If no treatment is furnished, we would expect screening to be billed with a low-level emergency department code

While one could potentially read the above as permitting a hospital to bill for an ED encounter where the patient did not see a physician, it is not clear whether that is, or ever was, CMS' policy. In light of CMS' response to my question during the April 19 Hospital Open Door Forum and my subsequent conversation with CMS as discussed in the note reprinted above, we have substantially revised the Q&A mentioned above.

Click here to view this Q&A from HCPro's Ask the Expert column.

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