Medicare Compliance & Reimbursement - 2016 Issue 11
Recovery Audit Contractors: RAC: The Doctor Isn't in? Don't Bill E/M for Diagnostic-Only ED Visits
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Article Overview
This article covers a Medicare recovery audit contractor review focused on emergency department claims for patients who are triaged but leave before being examined or treated by a qualified practitioner. It explains the general outpatient coverage framework, discusses why diagnostic testing may still be reported, and highlights that payer policies may differ from Medicare. The piece is aimed at hospital coders, billing staff, compliance teams, and revenue cycle professionals who work with emergency department outpatient claims and Medicare policy guidance.
Why This Topic Matters
These claims can draw audit attention, and improper reporting can create payment risk for hospitals. The article helps readers recognize the general compliance issue, understand the policy context, and check payer-specific requirements before billing.
Article Sections
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Region B Is on the Case
Introduces the recovery audit contractor review and describes the category of emergency department encounters under scrutiny. It also outlines the general billing context for triaged patients who are not seen by a practitioner.
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Don’t Report a Low Level Facility ED Visit, Either
Discusses Medicare guidance and related FAQ language about limited services in this setting. It also notes that payer policy can vary and may require separate verification.
What You Will Learn
- The general compliance issue involving emergency department encounters where a patient is triaged but not evaluated by a qualified practitioner
- How Medicare outpatient service coverage concepts apply to emergency department facility billing
- Why diagnostic testing and outpatient visit reporting are treated differently in this context
- When payer-specific policy review may be necessary
Who Should Read This
- Hospital coders
- Emergency department billing staff
- Revenue cycle professionals
- Compliance teams
- Outpatient facility billing teams
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