Ambulatory Coding & Payment Report
Reader Question: Coding LWBS
Question: Should I assign 99281 to claims when a patient is triaged but not seen?
Florida Subscriber
Answer: This situation has caused controversy across the country. Two views or issues are at stake. The first matter to bring to the physician's and hospital's attention is the fact that patients who leave without being seen (LWBS) are placing the ED at risk for an EMTALA violation. All patients who present for medical care to an ED must be given an appropriate medical screening exam (MSE) -- one that involves a history, exam and decision-making to determine if an emergency medical condition exists. In the case of a patient who is triaged but then classified as LWBS, the requirements of EMTALA have not been met.
Detailed documentation should be included in the chart to note what attempts were made to dissuade the patient from leaving.
Triage includes the chief complaint, vital signs and temporizing care, such as a bandage for bleeding. It does not conform to the requirements of an MSE. Therefore, if you triage a patient and he or she leaves without an MSE, you could have a problem if you then tried to charge for a visit that did not meet the federal requirements for the MSE.
The opposing view is that CMS (formerly HCFA) said that, in relation to the APC program, it wanted individual hospitals to determine the criteria for each facility level and use them consistently. If a facility determines that its triage function meets its unique requirements for 99281 (emergency department visit for the evaluation and management of a patient), it makes sense that this code be used. The patient was seen and evaluated, and in many cases treated, at a certain level in the triage process.
This philosophy separates the EMTALA MSE requirement from the triage service. This method is even more reasonable if the triage department continues to document the attempts at persuading the patient to stay and have the MSE. Nursing staff in this situation is definitely doing work that most would say deserves reimbursement, even if the patient decides to leave.
The only question left is the amount of weight placed on the absence of the physician documentation. CMS has said that the nursing levels should be determined by the facility based on its own criteria, which might not necessarily include the physician's component. The decision as to which approach to take is an individual one, because there are no specific guidelines.
Florida Subscriber
Answer: This situation has caused controversy across the country. Two views or issues are at stake. The first matter to bring to the physician's and hospital's attention is the fact that patients who leave without being seen (LWBS) are placing the ED at risk for an EMTALA violation. All patients who present for medical care to an ED must be given an appropriate medical screening exam (MSE) -- one that involves a history, exam and decision-making to determine if an emergency medical condition exists. In the case of a patient who is triaged but then classified as LWBS, the requirements of EMTALA have not been met.
Detailed documentation should be included in the chart to note what attempts were made to dissuade the patient from leaving.
Triage includes the chief complaint, vital signs and temporizing care, such as a bandage for bleeding. It does not conform to the requirements of an MSE. Therefore, if you triage a patient and he or she leaves without an MSE, you could have a problem if you then tried to charge for a visit that did not meet the federal requirements for the MSE.
The opposing view is that CMS (formerly HCFA) said that, in relation to the APC program, it wanted individual hospitals to determine the criteria for each facility level and use them consistently. If a facility determines that its triage function meets its unique requirements for 99281 (emergency department visit for the evaluation and management of a patient), it makes sense that this code be used. The patient was seen and evaluated, and in many cases treated, at a certain level in the triage process.
This philosophy separates the EMTALA MSE requirement from the triage service. This method is even more reasonable if the triage department continues to document the attempts at persuading the patient to stay and have the MSE. Nursing staff in this situation is definitely doing work that most would say deserves reimbursement, even if the patient decides to leave.
The only question left is the amount of weight placed on the absence of the physician documentation. CMS has said that the nursing levels should be determined by the facility based on its own criteria, which might not necessarily include the physician's component. The decision as to which approach to take is an individual one, because there are no specific guidelines.
- Published on 2001-08-01
Already a
SuperCoder
SuperCoder
Member
