# Billing For Charges Incurred When Patient Leaves Before MD Exam



## rrmclain (Apr 19, 2013)

We frequently have patients who come into our ER, undergo tests and procedures and then sneak out before the MD comes in to examine them.  Can we bill them for an ER Level Charge, an AMA Charge or just bill them for the charges incurred and can you soppy rationale to support the ability to do this?  Our previous ER Director allowed us to charge an AMA Level charge because even though the patient was not seen by the MD, all tests and procedures were based on established ER Protocols for the condition the patient presented with.  The MD who "was to see" the patient signed the orders verifying the treatment was provided based on Standards of Medical Practice.  Our current ER Director does not seem to have an issue about the thousands of dollars for tests and procedures we are writing off when these patients skip out.  Anyone else having this problem and how are you handling it and coding the visit?


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## mitchellde (Apr 19, 2013)

If you are billing for the facility then yes the facility can charge an ER level of service based on the system your facility uses for facility E&M.  you need to hgave a way of determining the level of service based on the utilization of facility resources excluding physician services.  If you are billing for the physician then there is no physician charge if he did not see the patient.  And of course you charge for all procedures/tests performed


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## Lomakema (May 20, 2013)

So how would you code for as a diagnosis code?  symptoms?


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## mitchellde (May 20, 2013)

yes symptoms, there must be somthing in the way of symptoms documented.


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## kristen.mercer (Aug 14, 2014)

We don't charge an ED level, we charge for the services rendered and bill a "statistical charge" of left without being seen.  As long as the orders are documented in Cerner, there's justification to bill for services (labs, CT scan...ect)


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## jimbo1231 (Aug 14, 2014)

*Right*

I agree about billing for facility services rendered. Although I get conflicting information about the facilities ability to charge say a 99281 if the doc never sees the patient.

With all of those patients "skipping out" your director might want to look at remedying that . Typically wait time is the reason. And wait time can be caused by many factors. But there are many consultants and systems out there these days (I'm not selling me, I don't do that) that can help a hospital with ER bottlenecks. Interestingly Scribes actually help with with throughput by freeing up the providers to see more patients. Even if you bill a low level and procedure on the facility side, typically there is no billing on the physician side. There is a loss of revenue on both sides.

Jim S.


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## mitchellde (Aug 14, 2014)

For facility billing the provider level and the facility level are mutually exclusive, they do. OT have to match ever and are calculated using entirely different criteria.  Even though the patient did not see the provider, facility resources were consumed and should be evidenced by the documentation of facility personnel.  The tool the facility uses should have a provision for yes even a level for one for patients that are triaged but not seen by the provider.  There is nothing wrong with this practice and it raises no eye


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## shborger@comcast.net (May 20, 2015)

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.Source


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