ED Coding and Reimbursement Alert

In the past, many hospitals attempted to screen out non-emergent patients and refer them back to their private physician, says John Turner, MD, PhD, medical director of documentation and coding compliance at Team Health in Knoxville, Tenn. This led to abuse, and eventually it resulted in the federal government enacting legislation to prevent the inappropriate transfer or discharge of patients.
 
This legislation is commonly known as EMTALA or COBRA. Turner explains that by this act, all patients presenting to the hospital and requesting medical evaluations must be seen without regard to their insurance status or ability to pay. Everyone must receive a medical screening examination before any conversations can take place regarding the payment and before any communication to a third-party payer to inquire about coverage, he says. Also, Medicare and Medicaid are constrained by the prudent-layman language of later acts. This language requires that all patients covered by these programs be seen and evaluated, and their visit be paid, if -- in the view of a prudent layman -- their problem could represent an emergency medical condition. Legislation is in the works to expand this requirement to all payers.
 
The best approach is to code the E/M level and the ICD-9 codes that are supported by the documentation provided. If reimbursement is denied or reduced, the appeals process is very effective, especially when supported by the prudent- layman legislation that many states have enacted and the federal government is working on. Remember -- managed- care organizations cannot deny medical care, they can only deny payment. Code the work done and deal with the reimbursement later.