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Can we bill E/M for patient who is triaged but leaves AMA?

  1. #11
    Default Thanks everyone
    Medical Coding Books
    I understand that everyone does this for payment, but what is being practiced doesn't meet what is outlined for an E&M code. This was a really great question tate, something I never really thought about. I will raise this question to my MAC to see how they view facility charging for nurse triage visit in ER. Thanks everyone for your comments and attempting to make me understand this.

  2. #12
    Columbia, MO
    Again facility is different. There so far have not been codes created for the facility to use to capture an encounter. There are now HCPC II codes for ER encounters but still several payers do not recognize them. The E&M code for the facility does NOT have the same guidelines as the physician. The facility must account for their utilization of resources using this E&M code. The nurse, the patient transporter the lab runner, the lights, exam room supplies... all of these things and more are consumed by the patient when they present to the facility and the only way the facility can communite this consumption of resources to the payer is via the E&M code. There is absolutely nothing wrong with the facility charging a higher E&M than the physician or a lower one. The levels are not expected to match. so when you say it does not match what is outlined for an E&M, you are comparing apples to oranges. The physician must comply with 95 or 97 guidelines for HX, exam, MDM... the facility must adhere to their own guidelines they create and hx, exam, MDM ... does not enter into their equation.
    Debra Mitchell, MSPH, CPC-H

  3. #13
    We use the v626 code and we don't have much of a problem getting paid.

  4. #14
    Columbia, MO
    Leslie I left town with out my HCPC II book which is never a good move. However the v626 does not look familiar. I cannot bring up in my memory the ED HCPC II codes created for facility use. Can you give me a brain boost and give me the narrative for v626? We have had a number of payers that have communicated to us to use the standard CPT codes 99281-99285.

  5. #15
    I'm butting in late but "facility evaluation and management" and "physician evaluation and management" are two TOTALLY different things. The facility such as a hospital, is billing a certain level of evaluation and management based on the resources used by the hospital. The hospital itself determines the criteria for each level because every hospital is different, some are smaller, some are bigger, have more costs, less costs, in a rural area, in an urban area, are 24 hours, are not 24 hours -- there's a lot of different factors. This is why if you have ever been to the ER yourself, you get EOB's and/or bills from BOTH the facility and the physicians who treated you. Facility evaluation and management has nothing to do with "history, exam, medical decision making" -- that's for the physician. The hospital has to make money too, right? Well that's how the facility E/M's come into play. You get seperate bills for any labs and/or testing performing on you, because when the hospital determines "facility E/M criteria and fees" they cannot include any services that are seperately reimbursed. This is why the hospital fees outweigh the physician fees -- they incur WAY more costs. A portion of the facility E/M could include, the electric, the lab runner, the supplies, your gown, the TV hanging on the wall, the phone in your room, the meals you eat anytime you want -- all of those are fixed costs into the associated fee-- but there are many variables, how long you are there, how much of the resources you use, etc. Physicians don't create their "own criteria" because, they don't incur nearly as many costs, typically the fee schedules are predefined, fee for service (most of the time, unless capitated) there's no variables, are reasonable and customary, the physicians are providing the medical service and cognitive labor (not the electric or the phone line). There's just too much! And don't worry about the hospitals charges "way too much" they are definitely accountable for their fees through many ways beyond belief, even though they create their own. Just think of it this way, say the hospital spends $10B per year (total guess, I have no idea) each and every single patient ENCOUNTER is a percentage of that cost. It's a lot more complex, but that basically sums it up.

    Here is a good link that can help you better understand:
    Last edited by ARCPC9491; 06-22-2009 at 09:26 AM.

  6. #16
    I believe the v626 is actually supposed to be V62.6 Refusal of treatment for reasons of religion or conscience. I don't think that is appropriate for leaving AMA, just my opinion.

    Laura, CPC

  7. #17
    Columbia, MO
    Oh I am sorry I thought she was saying that was the HCPC code. I should have recognized it as a dx code.. a little jet lag on me brain! No that would not be an appropriate code for AMA at all! It would have to be clearly documented that the patient stated they were refusing tx for those reasons not just up and leave for reasons not stated.

  8. #18
    No, I don't believe that it is appropriate at all either and have stated that to my supervisors to no avail. There is always an admitting complaint when the patient is triaged. Is that what should be used? And if so, is there something written somewhere that I could use to bring to my supervisors attention to help with this? This has been the source of many disagreements in our office.

  9. #19
    Columbia, MO
    The code itself is just inappropriate without documentation to support it. I would code the symptoms the patient presented with. They left for a reason it would appear unknown to the Ed staff. I would never for any reason append a dx code which is not supported by documentation. I think that is all you should need, just proof that it was not documented. This information is now being communicated to that patient's carrier which could have long range effects on the patient.

  10. #20
    Thanks Deb. I will pass this along at our weekly staff meeting. Maybe I will actually get somewhere with them

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