# Can we bill E/M for patient who is triaged but leaves AMA?



## ttate

I do not do Hospital Billing currently but have been asked if it is appropriate to bill if the patient leaves the ED before being "seen" or being "treated" by the physician.  I am under the impression that you can charge a low level E/M if they are triaged and then leave AMA if the documentation supports it...since the patient's vitals would have been taken, the reason for the visit would have been documented and there may have been "Standing Order" tests performed, like an EKG for chest pain or a pulse oximetry, etc.  If the documentation supports the medical necessity of all tests performed and the severity of the presenting problem is clearly defined, and the ED consistently follows the same protocol for all patients who leave AMA, I think the ED should be able to bill the appropriate E/M with a status code of 07???  Any insight would be very helpful.  Thanks~!


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## lovmoney69

Yes, as long as all of your bullet requirements are met and there is some sort of MDM initiated by nursing staff, eg. order for lab or EKG, oral meds, etc you can charge a 99281 for the triage.


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## maysons1703

*Stop, Think about it!*

You can charge the patient for services, but you cannot bill the insurance company if you do not have HPI/PE/MDM (ER is 3 out of 3). These elements have to be documented by a doctor and you don't have that with LWOBS. You will find yourself in the middle of RAC reimbursement. You may want to implement a form that mimics an ABN if the patient leaves without being seen.

Melissa Freeman, RHIT,CCS-P,CPC


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## mitchellde

If you are billing for the facility, as long as you meet the facility requirements for a level 1, 2, 3, 4 or 5 then that is what you may bill.  The hx, exam, decision making is all for the physician and has no bearing on the facility encounter level.  The facility should have facility criteria for the visit level that is followed for all patients.  It is very different from physician.  Also there are HCPC II codes for ER facility encounters, that some payers would prefer be used.


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## LTibbetts

I agree with mitchell. That is exactly how we do it in our ER. We also have a form that we created for AMA/LWOBS. It helps us show that the pt leaving is documented in the chart. We try to get the patient to sign it before they leave. They don't always comply and sometimes leave without letting anyone know. Also, we use t-sheets here (unfortunately..lol) for the pysician and another one for the nurses so the nurse t-sheet has the facility level fees documented on it and that is what we always charge for. If we went through the triage process and the patient had vitals, HPI, ect. done, then  you can definitely charge for that.


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## maysons1703

*???*

How are you justifying E&M levels when you don't meet the minimum requirements for an evaluation and management services.


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## mitchellde

The facility is different.  The facility does not have guidelines to follow like the physician.  The facility is required to come up with their own guidelines that they must follow, so they can make the determiniation as to exactly what constitutes a minimal visit.  They just have to follow the same quidelines for each patient.  It may not sound right but remember the facility must account for the utilization of their resources.


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## cpccoder2008

Our facility charges for it. Our physician's do not.


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## maysons1703

*???*



mitchellde said:


> The facility is different.  The facility does not have guidelines to follow like the physician.  The facility is required to come up with their own guidelines that they must follow, so they can make the determiniation as to exactly what constitutes a minimal visit.  They just have to follow the same quidelines for each patient.  It may not sound right but remember the facility must account for the utilization of their resources.



Where is this referenced? Or is this just standard practice? If this is true, what is stopping facilites from charging higher level E&M for AMA if this isn't standardized for facility charging? Does the insurance companies know that they are being charged for AMA's? What diagnosis are being assigned for these type visits? Symptoms only documented by a nurse? 

Melissa


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## 808coder

*E/M w/ AMA Facility side*

EVEN IF THERE IS NO WORK-UP but the pt was triaged, put in a room, had one or more of the following things done, meds p.o, put on a cardiac monitor, changed into a gown, etc YOU CAN CHARGE for this visit.  Again, this is for the FACILITY.  

Now if you have a pt who has done all this w/ a CC of Chest Pain, SOB, Syncope, why would your ER MD let this person leave without seeing them or attempt to see them?  Probably won't happen in 8 out of 10 cases, but it does happen.  This AMA would get charged at my facility, probably a low level because no tests were done but there will be an H&P by the MD to accompany why the pt left AMA and what we tried to do to get them to stay.

As stated in earlier comments about this, the facility should come up w/ a guideline and treat all the pt's the same.


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## maysons1703

*Thanks everyone*

I understand that everyone does this for payment, but what is being practiced doesn't meet what is outlined for an E&M code. This was a really great question tate, something I never really thought about. I will raise this question to my MAC to see how they view facility charging for nurse triage visit in ER. Thanks everyone for your comments and attempting to make me understand this.


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## mitchellde

Again facility is different.  There so far have not been codes created for the facility to use to capture an encounter.  There are now HCPC II codes for ER encounters but still several payers do not recognize them.  The E&M code for the facility does NOT have the same guidelines as the physician.  The facility must account for their utilization of resources using this E&M code.  The nurse, the patient transporter the lab runner, the lights, exam room supplies... all of these things and more are consumed by the patient when they present to the facility and the only way the facility can communite this consumption of resources to the payer is via the E&M code.  There is absolutely nothing wrong with the facility charging a higher E&M than the physician or a lower one.  The levels are not expected to match.  so when you say it does not match what is outlined for an E&M, you are comparing apples to oranges.  The physician must comply with 95 or 97 guidelines for HX, exam, MDM... the facility must adhere to their own guidelines they create and hx, exam, MDM ... does not enter into their equation.
Debra Mitchell, MSPH, CPC-H


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## LTibbetts

We use the v626 code and we don't have much of a problem getting paid.


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## mitchellde

Leslie I left town with out my HCPC II book which is never a good move. However the v626 does not look familiar.   I cannot bring up in my memory the ED HCPC II codes created for facility use.  Can you give me a brain boost and give me the narrative for v626?   We have had a number of payers that have communicated to us to use the standard CPT codes 99281-99285.


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## ARCPC9491

I'm butting in late but "facility evaluation and management" and "physician evaluation and management" are two TOTALLY different things.  The facility such as a hospital, is billing a certain level of evaluation and management based on the resources used by the hospital. The hospital itself determines the criteria for each level because every hospital is different, some are smaller, some are bigger, have more costs, less costs, in a rural area, in an urban area, are 24 hours, are not 24 hours -- there's a lot of different factors. This is why if you have ever been to the ER yourself, you get EOB's and/or bills from BOTH the facility and the physicians who treated you. Facility evaluation and management has nothing to do with "history, exam, medical decision making" -- that's for the physician. The hospital has to make money too, right? Well that's how the facility E/M's come into play. You get seperate bills for any labs and/or testing performing on you, because when the hospital determines "facility E/M criteria and fees" they cannot include any services that are seperately reimbursed. This is why the hospital fees outweigh the physician fees -- they incur WAY more costs. A portion of the facility E/M could include, the electric, the lab runner, the supplies, your gown, the TV hanging on the wall, the phone in your room, the meals you eat anytime you want -- all of those are fixed costs into the associated fee-- but there are many variables, how long you are there, how much of the resources you use, etc.  Physicians don't create their "own criteria" because, they don't incur nearly as many costs, typically the fee schedules are predefined, fee for service (most of the time, unless capitated) there's no variables, are reasonable and customary, the physicians are providing the medical service and cognitive labor (not the electric or the phone line). There's just too much! And don't worry about the hospitals charges "way too much" they are definitely accountable for their fees through many ways beyond belief, even though they create their own. Just think of it this way, say the hospital spends $10B per year (total guess, I have no idea) each and every single patient ENCOUNTER is a percentage of that cost. It's a lot more complex, but that basically sums it up.   

Here is a good link that can help you better understand:
http://www.ahacentraloffice.org/ahacentraloffice/images/EM_Coding_Report2.pdf


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## LLovett

I believe the v626 is actually supposed to be V62.6 Refusal of treatment for reasons of religion or conscience. I don't think that is appropriate for leaving AMA, just my opinion.

Laura, CPC


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## mitchellde

Oh I am sorry I thought she was saying that was the HCPC code.  I should have recognized it as a dx code.. a little jet lag on me brain!   No that would not be an appropriate code for AMA at all!  It would have to be clearly documented that the patient stated they were refusing tx for those reasons not just up and leave for reasons not stated.


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## LTibbetts

No, I don't believe that it is appropriate at all either and have stated that to my supervisors to no avail. There is always an admitting complaint when the patient is triaged. Is that what should be used? And if so, is there something written somewhere that I could use to bring to my supervisors attention to help with this? This has been the source of many disagreements in our office.


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## mitchellde

The code itself is just inappropriate without documentation to support it.  I would code the symptoms the patient presented with.  They left for a reason it would appear unknown to the Ed staff.  I would never for any reason append a dx code which is not supported by documentation.  I think that is all you should need, just proof that it was not documented.  This information is now being communicated to that patient's carrier which could have long range effects on the patient.


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## LTibbetts

Thanks Deb. I will pass this along at our weekly staff meeting. Maybe I will actually get somewhere with them


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## haileybspencer

*ER facility billing AMA*

In 2011 OPPS, CMS restated its position on "Triage-only" visits confirming that it does not specify the type of staff who may provide services.  "A hospital may bill a visit code based on the hospital's own coding guidelines which must reasonably relate the intensity of hospital resources to different levels of HCPCS codes.  Services furnished must be medically necessary and documented."  

However, in a 2012 Facility FAQ, CMS indicated that 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 qualified practitioner.  Services provided by a nurse in response to a standing order do not satisfy this requirement.  Since diagnostic services do not need to meet the requirements for incident to services, they may be coded even if the patient were to leave without being seen by the physician.


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