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Jennercoder

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Hello: I have read previous posts on this topic, but there seemed to be no clear definition.

I have a client hospital which wants to know if they can charge anything for triage by a nurse in the ER, if the patient leaves before they see the Dr. My online research has shown everything from using 99281, to using no Cpt with a flat fee and revenue code 451. So far, I'm not really comfortable with either...

Any thoughts on this? I have tried to find this in CMS, with no luck yet. Thanks in advance.
 
hendenml said:
Hello: I have read previous posts on this topic, but there seemed to be no clear definition.

I have a client hospital which wants to know if they can charge anything for triage by a nurse in the ER, if the patient leaves before they see the Dr. My online research has shown everything from using 99281, to using no Cpt with a flat fee and revenue code 451. So far, I'm not really comfortable with either...

Any thoughts on this? I have tried to find this in CMS, with no luck yet. Thanks in advance.
Click to expand...

The only code you could potentially use in the CPT book would be 99211 because the patient did not see a physician. There may be a facility charge that could be billed, or you could certainly make up an internal code with a flat fee that you bill if a patient is triaged by the nurse but leaves AMA. Getting reimbursed will be a whole different issue. This would be similar to billing for no show appointments in the doctor office. Not covered by insurance, and some insurances may not allow it to be billed to the patient.
 
Hospitals bill per APC and OPPS which means the hospital gets to set their own facility specific criteria for what would constitute a 99281, 99282, 99283, 99284, or 99285.. Just because they did not see a physician in the facility does not mean the facility cannot charge a level 2,3,4, or even 5. It is based on their own unique facility criteria. For ER they would not use a 99211 at all. Insurance will reimburse the facility as long as the diagnosis is logical for what ever level is submitted. For your on line research you need to look under APC and OPPS
 
mitchellde said:
Hospitals bill per APC and OPPS which means the hospital gets to set their own facility specific criteria for what would constitute a 99281, 99282, 99283, 99284, or 99285.. Just because they did not see a physician in the facility does not mean the facility cannot charge a level 2,3,4, or even 5. It is based on their own unique facility criteria. For ER they would not use a 99211 at all. Insurance will reimburse the facility as long as the diagnosis is logical for what ever level is submitted. For your on line research you need to look under APC and OPPS
Click to expand...

There you go! For those of us who deal in professional coding the facility side is quite confusing! I had no clue that facilities could set their own criteria or that just because a patient did not see a physician they could still bill a relatively high level of service. Good to know!
 
Yes the facility E&M is based on the resources used by the facility not on physician services since the physician will be billing for that.
 
thanks

Thanks everyone, for your help! This discussion area of the AAPC website is a valuable resource, especially since I am the only Coder where I work. :D
 
A friend of mine went to the ER and was triaged, temp and blood pressure taken and discussed what the problem was. She was then placed in the waiting room and left there for 5 hours without ever going back to a room. She left and went to a different ER. The first hospital is billing her insurance for an ER visit even though there was no treatment or decision making provided. Is this legal? What would they have charged for?
 
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