Medicare Compliance & Reimbursement

Sometimes, the EMTALA regulation butts up against billing and coding rules, said compliance expert Duane C. Abbey, PhD in his recent AudioEducator presentation. Take the hypothetical case of “Sara’s Stuffy Nose.”

Sara is a Medicare patient who woke up with a stuffy nose. She called her physician this morning, but the answering machine at the clinic indicated that the doctor was out of town and, if there were any problems, she should simply go to the emergency department at Apex Medical Center.

At the ED, the triage nurse determined that while Sara has a stuffy nose, it probably is not an emergency. Of course, there’s always the potential of an emergency medical condition, but in this instance, the nurse determined that it is not an emergency. Therefore, the triage nurse must be qualified through hospital policies and procedures to be able to perform the MSE.

Now if Sara was to leave at this point, the hospital will have satisfied its EMTALA obligation.

However, Sara wants to see a doctor anyways. The ED physician examines her and he prescribes an over-the-counter decongestant. Now this has become some sort of a clinic visit.

Now, how should the hospital code and bill for this? CMS would recommend that the visit be billed as a low-level ED visit, such as 99281 (Emergency department visit for the evaluation and management of a patient …).

But, what if the doctor didn’t see her? What if it was just the nurse? The hospital is meeting its EMTALA obligation, but not meeting the conditions of payment relative to having a services incident-to those of a physician.

In this case, billing for the 99281 is a problem, particularly if the nurse prescribed the decongestant, as the service cannot be considered “incident-to” that of a physician.