ED Coding and Reimbursement Alert

Question: We have a patient who comes to the ED to receive Procrit injections. His diagnosis is agnogenic myeloid metaplasia (289.89, Other specified diseases of blood and blood-forming organs), which isn't listed as a payable diagnosis on the Medicare local medical review policy for Procrit. He comes in for the injection weekly. How should I report this? And do I need to give him an advance beneficiary notice?
      
Arkansas Subscriber
 
Answer: On the professional side, the first question you need to answer is whether this patient meets the medical-necessity requirements for a physician evaluation. One possibility is that the patient may not require an evaluation and management service at all. However, some hospitals have taken the view that all patients presenting to the emergency department require a formal triage process and a medical screening exam by the ED physician (at minimum). Frequently, hospital legal counsel is involved in guidance regarding these issues.

Your question regarding the advance beneficiary notice seems more relevant to the facility side, because the charge you would be reimbursed for is a supply charge for the Procrit.

Generally, Medicare discourages the issuance of ABNs in the ED. The government's position is that patients having a medical emergency are not capable of making adequate decisions and may forego needed treatment due to financial concerns. So, if you do decide to use an ABN, you should seek legal guidance from the attorney at your facility.