Unlike physician offices and hospitals, emergency departments see patients with a variety of illnesses and injuries on an unscheduled and episodic basis. Consequently, many EDs have to deal with treatment scenarios unfamiliar to other healthcare providers. For example, in a busy ED, patients may often get frustrated with long waits to see the physician and leave without being seen (LWBS). Or, discouraged by the wait or unwilling to be admitted to the hospital after seeing the ED clinical staff, some patients leave the department against medical advice (AMA) before their treatment is complete.
ED managers and coders are often required to both keep track of billable services and ED utilization data (which patients are seen and what services are provided), sometimes incorrectly allow charging for patients who are never actually treated in the ED, or, at the other extreme, do not code for services provided because the patient is not officially discharged from the department.
We interviewed two ED billing experts to clarify the limits on charging for services provided to patients who leave AMA.
for the Service Provided and Documented
The main thing to keep in mind is that you can and should code for the services actually provided to the patient in the ED.
Even if the patient chooses to leave the department, the service was still provided. You code the chart just like any other, based upon the documented history, physical exam, and medical decision-making, explains Barbara Cole, RN, BSN, CPC, vice president of pre-billing operations for Reimbursement Technologies, Inc., an emergency medicine coding company based in Blue Bell, PA.
A common scenario in many EDs: Patients come in with suspected broken bones, are sent to radiology for x-rays, become frustrated by the length of time it takes to get them, and decide to leave, says Jackie Davis, president and CEO of Term Billing, Inc., an emergency physician group billing company based in Arlington, TX.
For example, a child who has fallen will come in and there is usually a protocol where the nurse will order the x-rays first. The doctor may come in and do a low-level exam (Let me look at your arm), but usually only the nurse is present. Then the patient and the parent get frustrated while waiting for the x-ray and decide to leave, she illustrates. For that we could code a level 1 or level 2 (99281 or 99282), probably a low-level visit.
Choosing Not to Charge Low Levels