02/24/2016    

To Bill or Not to Bill?

We had an unusual experience this morning. A new
patient checked in, paid their copay the medical
assistants entered his medical information into
the EHR and he was roomed. At the very moment my
medical assistant started to take the patient’s
vital signs the patient stated he suddenly could
no longer lift his left arm. The MA came and got
me immediately and I took one look at the patient
and asked him to smile for me, revealing obvious
left sided facial droop.

We called 911 and while we waited for EMS to
arrive I explained in detail what was happening
and that treatment would likely require t-PA
within the next 2-3 hours at the hospital. I did
my best to keep the patient and his wife calm and
we put together a medical history summary and med
list for EMS. EMS arrived and then took him to
the hospital to treat his stroke.

I feel blessed that we were able to identify the
symptoms and get help as quickly as possible. The
patient will likely make a much better recovery
due to our quick diagnosis and action.

The incident was quite disruptive to our morning
workflow (a big firetruck in your parking lot
tends to turn patients away…) and we had to
reschedule several patients as a result. I also
now have an unfulfilled encounter in my EHR
system asking me how to bill the visit since the
patient checked in. I’m certainly willing to
write off the visit, but I also feel that I did
perform an emergency E&M that may very well have
saved that mans life and that in a professional
sense our office should be compensated in some
way if appropriate. I don’t want to seem like a
heartless money-focused businessman.

I simply find myself in a moral quandary between
the two opposing view points of the helpful
citizen side of me that would have done the same
exact thing for that man had he collapsed in
front of me at the mall, vs the small business
owner doctor that evaluated a patient in his
office and had to take the same emergency action.

So I ask for the opinion of PM News readers to
assist me in this decision. Also, for those in
favor of billing the patient’s insurance, I ask
how they would bill the encounter.

Other messages in this thread:

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02/26/2016    Timothy P. Shea, DPM

To Bill or Not to Bill?

I see absolutely no ethical or clinical reason
for not billing for this type of encounter. As a
treating healthcare provider, you supplied
exactly what you are trained to do "healthcare."
Congratulations to you and your staff for picking
up the early signs of what appears to be a
vascular incident and, following through with the
appropriate actions in triaging and referral to
the proper setting for treatment.

These type of encounters, although infrequent,
and sometimes hair raising and definitely
disruptive, are also the ones which give the best
sense of satisfaction in the field we practice
in. Clinically and ethically, you acted
completely responsible and professional.

I see no reason why you can't bill for this
event. It was an initial office visit (encounter)
which required a medical work up, physical exam,
paperwork, and some form of treatment. The key
here I believe is TIME and severity of CLINICAL
decision-making. Although not foot specific in
the long run, your expertise in medical decision
making was extensive, the degree of severity was
high and , disposition of the case was complex.

The time factor greatly exceeds any standard
initial visit. So I believe you easily fall into
the elevated 9920X (4-5) codes. Obviously, your
note should document the whole scenario as you
have already done.

The other patient visits that were lost or
detained you are credited for in some other place
in the cosmos. But this patient you have every
right , and should not feel hesitant in billing
for your services.

In over 43 years of practice, I have had my fair
share of these type of encounters and have acted
and billed the same way.

Timothy P. Shea, DPM, Concord, CA