ED Coding and Reimbursement Alert

Unlike physician offices and hospitals, emergency departments see patients with a variety of illnesses and injuries on an unscheduled and episodic basis. Consequently, many EDs have to deal with treatment scenarios unfamiliar to other healthcare providers. For example, in a busy ED, patients may often get frustrated with long waits to see the physician and leave without being seen (LWBS). Or, discouraged by the wait or unwilling to be admitted to the hospital after seeing the ED clinical staff, some patients leave the department against medical advice (AMA) before their treatment is complete.
ED managers and coders are often required to both keep track of billable services and ED utilization data (which patients are seen and what services are provided), sometimes incorrectly allow charging for patients who are never actually treated in the ED, or, at the other extreme, do not code for services provided because the patient is not officially discharged from the department.

We interviewed two ED billing experts to clarify the limits on charging for services provided to patients who leave AMA.

for the Service Provided and Documented

The main thing to keep in mind is that you can and should code for the services actually provided to the patient in the ED.
Even if the patient chooses to leave the department, the service was still provided. You code the chart just like any other, based upon the documented history, physical exam, and medical decision-making, explains Barbara Cole, RN, BSN, CPC, vice president of pre-billing operations for Reimbursement Technologies, Inc., an emergency medicine coding company based in Blue Bell, PA.

A common scenario in many EDs: Patients come in with suspected broken bones, are sent to radiology for x-rays, become frustrated by the length of time it takes to get them, and decide to leave, says Jackie Davis, president and CEO of Term Billing, Inc., an emergency physician group billing company based in Arlington, TX.

For example, a child who has fallen will come in and there is usually a protocol where the nurse will order the x-rays first. The doctor may come in and do a low-level exam (Let me look at your arm), but usually only the nurse is present. Then the patient and the parent get frustrated while waiting for the x-ray and decide to leave, she illustrates. For that we could code a level 1 or level 2 (99281 or 99282), probably a low-level visit.

Choosing Not to Charge Low Levels

Often, in cases of low-level E/M services, Term Billing ends up not reporting these codes for AMA patients because it generates a lot of ill will with patients and payers, she notes. You should certainly feel able to bill for any service the physician provides, says Davis. But, as in the previous example, if the patient gets a bill for that service, they are probably going to complain to the hospital administration, she adds. We discuss these issues up front with our client physician groups. A lot of times, we would code that visit, the patient would complain to hospital administration, the administrator would call the physician, who ended up calling us and telling us to write off the charge anyway. It is more cost efficient to not charge the visit.

Reimbursement for a level 1 or level 2 E/M service is so low that it does not justify the office work for a charge that is likely to get written off anyway. Davis says her groups are more likely to want to charge patients when the service provided is high level and the patient truly left AMA.

You also have cases where the patient comes in, say with chest pain, and the physician does an extensive workup, including perhaps a consultation with another physician and orders several tests, she explains. The tests come back and the physician spends time talking with the patient and going over options and then the patient just decides to leave.

Davis says her group definitely charges patients for the ED services in these situations because the physician spends a lot of time on the patient workup, justifying a high level of service, and because the patient does not leave out of frustration with poor attention in the ED. Its more of a case of, I know I need to stay here for more diagnostics or perhaps you might want to admit me, but I am choosing to leave against medical advice, she explains.

Cole agrees, saying she has no problem reporting a high-level code for AMA patients as long as the documentation supports the codes chosen. If the medical decision-making is high and the history and physical supports it, we would code a level 5 even if the patient chose not to continue treatment, she says.

Avoid Insurance Only Billing

Some ED groups, frustrated by several low-level AMA visits, will flag the account insurance only, meaning that they report the code to a patients third-party payer to receive the insurance portion of payment, but do not bill the patient for their portion, if there is a patient fee. This is a bad practice and a fraudulent one, says Davis.

You can get into real trouble if you have a practice of billing insurance only, she notes. That is often a red flag
for auditors.

Physicians and patients both have contracts with third-party payers stipulating what portion of the services the patient and payer are each responsible for paying. Billing the insurance company, while writing off the amount the patient would pay, is in violation of these agreements. Not only do groups who practice insurance only billing put themselves at risk of a Medicare fraud investigation and charge, but they may be held liable for significant civil penalties for breach of contract with their private payers. Davis recommends that if the group does not want to charge the patient, then they must write off the entire charge.

LWBS is Not the Same as AMA

Another pitfall is billing for patients who leave without being seen as if they left AMA, says Davis. If the patient is not seen, there is no charge, she emphasizes. We did a couple of hospital audits and found they were charging a visit level for patients that werent even seen. They were registered in the deparment and seen by the triage nurse, but the triage nurse never even spoke to the doctor about them before the patient left. It was a low priority (non-emergency illness), and when they went to the waiting room to call them, the patients
werent there.

One ED was billing all of the AMAs and LWBS patients as a level 2 E/M service no matter what, she relates. You cannot do this. Some people think LWBS is the same thing as AMA, but it is not.

Again, billing all AMAs at a certain level is also incorrect. For patients who leave AMA after being seen by an ED physician, nurse, or mid-level provider, the coder should report the services that were provided to the patient. If the patient chart says LWBS, no charge can be supported, Davis states.