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Thread: ER vs Clinic charging

  1. #1

    Default ER vs Clinic charging

    AAPC: Back to School
    I am hoping that someone can help me with this......

    I work at a facility in where there are advertised "clinic or walk in" charge times during the day. There are times when a patient will present with an acute injury so even though it may be during "clinic" times the patient may be charged with an "ER" charge based on the fact that they have an injury in which they seeked medical attention for. Also any time a patient is given any kind of IV or IM medication we charge and automatic ER charge.

    That being said.....we had a patient that presented with a finger abrasion that happened early in the day. This patient waited for "clinic" hours to be evaluated. It was coded charged out and an "ER" because the injury happened prior to arrival and the patient was also given a tetanus shot. Patient is wanting the charge to be changed to "Clinic" level because of the time of day he was seen.

    Does anyone know of any guidelines that govern charging in the ER?


  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default Clinic visit

    The patient specifically waited until clinic hours and presented for a clinic visit (I'm guessing the patient does not have a primary care physician). If you are advertising clinic hours and patient presents for same, I feel it would be unethical to switch her to ER charge just because the nature of the problem is an injury. It's not like she was brought in by ambulance from an MVC. She came on her own, and even waited for the clinic hours.

    Just my opinion

    F Tessa Bartels, CPC, CEMC

  3. #3


    What if the injury happened just prior to arrival? What if the patient fell and broke their arm and drove themself to the ER? I guess we are having a hard time diferentiating between what is an emergency vs clinic.

  4. #4


    I have to agree with Tessa 1000%. I personally think it is fraud being the only reason they want to do ER charges is they are a lot more money than a clinic charge.

  5. #5
    Join Date
    Apr 2007
    Columbia, MO


    I agree with Tessa also you cannot change the circumstances midstream. If the place of the encounter is stated as a clinic and this is what the patient present for then it is a clinic encounter. Lets do the what if scenario:
    What if this were an ER and the patient presented just for a sore throat because the office is closed, would it be appropriate for the ER to charge as a clinic encounter based on the type of illness?
    I think if the patient presents to the clinic during stated clinic hours then unless they have to be transported to the ER for critical status, regardless then of type of illness or whether you administer medications it is a clinic encounter you cannot change this to ER.
    Also to charge a 450 revenue center for the facility doesn't there need to be criteria met for an ER?

    Debra A. Mitchell, MSPH, CPC-H

  6. #6


    We have one Emergency Department in a critical access hospital. The clinic hours/express care hours are from 4:00 p.m. to 8:00 p.m. Monday thru Friday. On the weekends and holidays it is from 8:00 a.m. to 4:00 p.m. We do not have a separate clinic building. We do not have a triage nurse in the ED. E/M charging is done by the coders at time of code assigment.

    What would you charge for a patient that requested a tetanus shot during clinic hours who cut his finger prior to arrival?

    What are other circumstances that you would charge for an ER instead of a clinic. (Obviously excluding cardiac arrest, mva)

    Personally I do not think is should be up to the coder to decide whether it is a clinic or ER visit.

  7. #7

    Default No Triage Nurse?

    I'm trying to understand exactly what you have. Are all of these patients coming to the ED intially and then being triaged.....Without a triage nurse?...to Express Care? Is this Express care in the ED? Many EDs offer express type care in the ED as a means of improving patient throughput, decreasing wait times for less acute patients etc etc. But the fast care area must follow protocols of ED, 24 hour availability etc. to bill as ED services.
    Also I'm pretty certain that EDs are required by State Regs and probably CMS and certainly COBRA rules to have triage.


  8. #8
    Join Date
    Apr 2007
    Louisville, KY


    Actually, I'm going out a limb here. Charging ER codes may be appropriate, if you can substantiate that the level of care required was the determining factor for code assignment. Since you're coding for the facility and CMS has yet to produce any explicit guidance on facility clinic and ER coding, the institution (facility/hospital) holds the right to determine the appropriate E/M level based on everything except physician work.

    What this means is that if infusions, injections and similar-intensity nursing services fall to the ER code set, then that is a reproducible method of determining OP code levels and meets the intent of CMS's existing guidance. I'd just ensure that whatever method is employed is done so consistently.

    In the meantime, "advertising" clinic hours and charges may not be the best approach with ER services. I'd be reluctant of that, but not much else. One thing that administration and clinicians must understand is that coding and charges are determined not by the time of the encounter, but by the level of care required (medical necessity).

    I hope this helps. Check out the previous OPPS guidance for ERs here


    I am not a whiz with the CMS website searches, so you may have to refine it.

    Good luck!
    Last edited by kevbshields; 10-06-2010 at 05:46 PM.
    Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I

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