Health Information Management

Q&A: Can we charge ED visits if patients don’t see a physician?

APCs Insider, August 8, 2014

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Q: We have a new ED director who wants to capture all of our ED visits to be sure we get our productivity credits and revenue. He wants to charge a low-level ED visit for the patients who come in, are registered and triaged by a nurse, but leave before they see the ED physician. He says that we have expended facility resources, so we should get paid for those resources. I believe our facility did this a long time ago, but stopped for some reason (before my tenure here, so I don’t know the details). Is this something we can implement?
A: This is not a scenario that should be reported with an ED visit level, even the lowest level. All hospital provider services must be provided “incident to” a physician’s service. When a patient comes to an ED for assessment and management of an issue, a physician service must be involved to meet that requirement. According to the Medicare Benefit Policy Manual, Chapter 15, section 60.1:
Incident to a physician’s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.
CMS also posted FAQ 2297 regarding this topic:
Can hospitals bill Medicare for the lowest level ER visit for patients who check into the ER and are "triaged" through a limited evaluation by a nurse but leave the ER before seeing a physician?
No. The limited service provided to such patients is not within a Medicare benefit category because it is not provided incident to a physician's service. Hospital outpatient therapeutic services and supplies (including visits) must be furnished incident to a physician's service and under the order of a physician or other practitioner practicing within the extent of the Act, the Code of Federal Regulations, and State law. Therapeutic services provided by a nurse in response to a standing order do not satisfy this requirement.
Depending on your facility’s chargemaster policy, you could add a tracking item to collect the data internally when patients leave the ED before seeing the physician.
Editor’s note: Denise Williams, RN, CPC-H, seniorvice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Florida, answered this question.

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