# Patient Left ER before being seen by MD



## DMSB00 (Sep 25, 2009)

Question - Occasionally we have patients who come to ER and are seen by nursing staff (for triage) but end up leaving before being seen by the MD. The Business Office wants to charge minimal triage/facility charge for these but in order to bill this there needs to be an ICD-9-CM Code to go on the claim. From a coding perspecitve, I am not sure how we would do this and still follow the Official Coding Guidelines because we cannot DX Code from nursing documentation. Wondering if others have come across this or have you just decided that you keep that documentation for record/risk purposes but do not charge anything is there isnt any documentation to code from?


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## mitchellde (Sep 25, 2009)

In our facility these usually came out as a no charge due to the way we had our "tool' set up for visit levels, we used points and these visits did not gain enough points for a low level encounter as we had anythoing with less than 10 points as a 0 visit level.


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## kevbshields (Sep 29, 2009)

I've also seen this done where the documented chief complaint (usually a sign or symptom, not a diagnosis) is coded along with V15.81 (for non-compliance) and a low-level ER visit, usually 99281.

On the facility side you have documentation to code from:  the nursing notes.


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## LLovett (Sep 29, 2009)

I was in a conference a few months ago and this was one of the topics. I am not at my desk so I can't site exactly what was said but the bottom line was these were not billable because the doctor did not see the patient therefore you can not bill incident to the physician.

If I remember I will try and pull my source documentation out tomorrow when I am at my desk and post that.

Laura, CPC, CEMC


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## gailmc (Sep 29, 2009)

We bill the facility charge based on nursing documention, but do not bill for the ED visit since there wasn't any face-to-face time with a provider.


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## LTibbetts (Oct 1, 2009)

gailmc said:


> We bill the facility charge based on nursing documention, but do not bill for the ED visit since there wasn't any face-to-face time with a provider.



We do the same thing. Since the patient was triaged, then we can charge a facility fee, but there is no pro fee added to the account, so it is a no-charge visit with the  chief complaint and a V-code as a dx.


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## DMSB00 (Oct 9, 2009)

Where in the coding guidelines does it say you can code from nursing notes if you are coding for the facility side? I dont think it distinguishes this. If thats the case wouldnt we be able to code all hospital visits from nursing documentation? The only thing I am aware of where we can code from nursing notes is on ulcer staging and BMI stuff per coding guidelines. Is there something else in there that I missed or where are you getting the info that we can code from nursing notes if we are coding the facility side?


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## LTibbetts (Oct 12, 2009)

DMSB00 said:


> Where in the coding guidelines does it say you can code from nursing notes if you are coding for the facility side? I dont think it distinguishes this. If thats the case wouldnt we be able to code all hospital visits from nursing documentation? The only thing I am aware of where we can code from nursing notes is on ulcer staging and BMI stuff per coding guidelines. Is there something else in there that I missed or where are you getting the info that we can code from nursing notes if we are coding the facility side?




Each hospital has its own set of guidelines in place for facility coding. Maybe check with someone in your hospital that works with the CDM or maybe the manager of the HIM department or the manager of your ED department and they may have that set of guidelines for you to review.


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## mitchellde (Oct 12, 2009)

Leslie is correct,  A facility is different and uses the visit levels as per their own criteria for a level, that is why I indicated that in the facility I worked at a visit as you suggested would come to less that 5 points which was a 0 visit.  in someone elses facility it would be a level 1 and so on.


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## eadun2000 (Oct 19, 2009)

DMSB00 said:


> Where in the coding guidelines does it say you can code from nursing notes if you are coding for the facility side? I dont think it distinguishes this. If thats the case wouldnt we be able to code all hospital visits from nursing documentation? The only thing I am aware of where we can code from nursing notes is on ulcer staging and BMI stuff per coding guidelines. Is there something else in there that I missed or where are you getting the info that we can code from nursing notes if we are coding the facility side?



Facility ER coding is not the same as physician ER coding.  You CAN code from the nurses notes for a lwobs patient as long as they were triaged and there are notes.  That is following the ACEP guidelines.

Hope this helps.


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