Revenue Cycle

Tip: Billing for services while a patient is unstable

Medicare Update for CAHs, November 2, 2011

Consider this scenario: A Medicare patient is brought the emergency department with a diagnosis of acute myocardial infarction. Although one of the ED physicians had been working on the patient for 15 minutes, the patient was still unstable. A cardiologist is called in to consult and orders a specialized diagnostic x-ray, but under the Medicare coverage policy, Medicare did not consider the x-ray to be medically necessary. Due to the patient’s condition, the hospital performed the x-ray prior to stabilizing the patient without attempting to have the patient sign an ABN, and Medicare denied the coverage for the x-ray on medical necessity grounds.

In this situation, may the hospital collect the full balance due from the patient, since the patient’s condition precluded presenting an ABN to the patient prior to providing the x-ray?

No. Even if the hospital had presented an ABN prior to performing the x-ray, the ABN would have been ineffective because CMS and the OIG take the position that an ABN should not be presented in an emergency situation when the patient is unstable. This is may be an example of a situation where it would be advisable to appeal the denial. <Medicare Claims Processing Manual, Chapter 30 § 40.3.7>

This tip was adapted from HCPro’s Medicare Boot Camp® - Critical Access Hospital Version.

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