Health Information Management

Q&A: Coding for ED patients who don't see physicians

APCs Insider, November 15, 2013

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Q: A patient presents to the ED and is just triaged. The patient received Motrin® and then left prior to seeing the physician. No physician will be signing off on the chart. We do have advanced nursing protocols set up and signed off by the ED medical director allowing the nursing staff to administer Motrin. The facility used its resources to take care of the patient not knowing the patient was going to leave—so would there be a nursing assessment charge that would apply? If so, what code could be used? Same scenario as above but instead of Motrin, patient received an EKG. Would a nursing assessment apply, and, if so, which code? Or would it be an E/M code?

A: All services provided by a facility must be incident to a physician’s service. In the scenario you describe, this requirement is not met, as the patient has not been evaluated by a physician or non-physician practitioner who is licensed to diagnose and treat patients. CMS guidance has noted that standing orders may be used to prevent delay in patient treatment, but physician involvement is still required in the treatment of the patient. The CMS website contains the following FAQ that addresses this situation:

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.

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, chairman, CEO, and founder of Health Revenue Assurance Associates, Inc., in Plantation, Fl., answered this question.

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