Wiki Referral to ER

[irma011]

Where does ER recommendation fall under Risk on the MDM chart? Majority of the time the provider will note "Sent to ER for further additional workup" but of course they don't lists any risks associated. So I'm a little confused on whether this would fall under Low, Moderate, or High? I know High Risk states "decision regarding hospitalization" but sending them to the ER for further evaluation doesn't necessarily indicate the patient will be hospitalized. Can someone help clarify this up? Thanks in advance!

 

[rthomas@impcna.com]

Where does ER recommendation fall under Risk on the MDM chart? Majority of the time the provider will note "Sent to ER for further additional workup" but of course they don't lists any risks associated. So I'm a little confused on whether this would fall under Low, Moderate, or High? I know High Risk states "decision regarding hospitalization" but sending them to the ER for further evaluation doesn't necessarily indicate the patient will be hospitalized. Can someone help clarify this up? Thanks in advance!

What is going on with the patient that the provider feels the need to send to the ER? Does the documentation state why provider is sending to the ER? If not, provider may need to provide a little more documentation. Did the provider call the ER a head of time to give discuss the case with the ER provider?

 

[irma011]

What is going on with the patient that the provider feels the need to send to the ER? Does the documentation state why provider is sending to the ER? If not, provider may need to provide a little more documentation. Did the provider call the ER a head of time to give discuss the case with the ER provider

3 month old was vomiting after every feeding & has not had a wet diaper since previous night at 7pm. Provider instructed mother to take the patient to the ER for evaluation/concerns of possible dehydration due to poor feeding intake. Provider did not call the ER to give a run down of what was going on for this particular case, but IF provider had documented "spoke with Nurse Dawn & report given", would it make a difference?

 

[rthomas@impcna.com]

I would consider this to be a high risk given of the age, the problem and the need to be transferred to another facility that could provide a higher level of care. Something to remember though, if your provider has admitting privilege at that hospital and the patient gets admitted under your provider then you wouldn't be able to charge for the office E/M & hospital H&P since it's all related. Whenever any of our providers send a patient to the ER to be evaluated, the provider calls and speaks directly to the ER Physician letting the ER doc know what is going on with that patient and what we had done in the office prior to ER arrival.
If the provider had documented that he called and gave patient report to the ER provider, then it would count under data as discussion of management w/external physician/other qualified health care professional/appropriate source.