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Avoid denied claims for ED diagnostic testing

Patient Financial Services Weekly Advisor, May 7, 2004

Medical-necessity determinations in the emergency department (ED) can be a controversial subject. Section 944 of the MMA says tests or services will be payable by Medicare if they were reasonable and necessary based on the information the practitioner had at the time they were ordered, and based on the patient's complaint or presenting symptoms.

Valerie Rinkle, MPA, revenue-cycle director at Asante Health System in Medford, OR, says there are some challenges associated with the rule. The edits Medicare has in its system are not specific enough to drill down to know that the admitting diagnosis is the one that covers the code, as opposed to the principal diagnosis. You'll still get rejections in this circumstance and you'll only be able to achieve payment through appeal, she says.

Rinkle offers three areas to examine and resolve:

1. Implement a documentation process in which there's an extra check by your ordering physicians in the ED that says they're ordering the test or service based on the presenting condition.

2. Use the process with other managed-care plans or Medicaid plans that may be trying to deny services ordered in the ED. If you can show that they were ordered prior to completion of the screening as part of the diagnosis of the case, they should pay it just as Medicare would. It falls under the umbrella of the Emergency Medical Treatment and Labor Act (EMTALA), she says.

3. Look at the timing of the interpretation. You may need to educate the ED physicians to ensure that their documentation or dictation, written notes, or their interpretation for screening and completing the screening and stabilization of the patient are correct. If a full-fledged interpretation occurs later, have a process in place to get back to the patient if there is a different interpretation that requires follow-up.

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