HCFA published guidelines in July '98 that made it clear that triage is an
act of sorting patients by severity, is not a proper medical screening
exam (MSE) and may not be used to determine whether or not an emergency
medical condition is present.
The hospital may not call for prior authorization before the MSE. It also
may not by contract or any other agreement with any third party payor
(including Medicaid MCO's) send a patient from the ED to a physician's
office before the MSE.
It is important to remember that the MSE includes not only an appropriate
clinical evaluation, but any lab or x-rays that one would normally obtain
in the course of evaluating similar patients with the same presenting
A proper medical screening examination can only be performed by a
physician, unless otherwise stated in the hospital's rules and
regulations, or the hospital's bylaws as approved by the hospital's
governing body. If a non-physician performs the MSE it must be within that
person's legal scope of practice. For example, it is common practice for
an L&D nurse to evaluate how far along a patient is within the birthing
process and determine the need for physician (or mid-wife) presence. An ED
nurse cannot make the determination of what labs or x-rays may or may not
be indicated for a particular presenting condition nor make a clinical
interpretation of the results; it is not within their scope of practice.
Narrowly defined nurse initiated guidelines for obtaining x-rays or lab
tests are not substitutes.
The reality is only physicians and mid-level providers can perform the MSE
in the ED. Two things that can bring HCFA to your door is a nurse MSE and
the patient being seen by their PCP on the same day they came to the ED.
I disagree with Connie as to the level of billing. You should bill to the
appropriate level of physician work involved in the MSE. CPT 99281 ("Level
1") involves almost no physician work, e.g. a patient comes to the ED only
for a tetanus shot. The degree on physician work, including medical
decision making and risk, even for a "cold" dictates a higher level of
service (please refer to the vignettes in the CPT book). The CPT modifier,
"-32" "mandated services," can be used to indicate a MSE. This code is
added to the E&M visit code, e.g. 99283-32.
There are two reasons why most bills for a MSE get rejected: 1) an
inappropriate diagnosis code (ICD-9-CM) and 2) lack of prudent layperson
ED diagnosis coding should be based on symptoms and complaints. If the
patient presents with a fever and no other findings, then "fever" (780.6)
and not "viral syndrome" (079.99) should be used. Codes V82.8 (special
screening for other specified conditions) or V82.9 (special screening for
unspecified condition) may be used as an additional (but not primary)
diagnosis for the MSE. The appropriate coding will also assist the
hospital with its APC since there is no APC for just a MSE.
The chart should reflect why the patient or parent thought the presenting
problem was a medical emergency ("prudent layperson justification"). This
will aid you in getting paid on appeal, if necessary. Medicaid MCO's are
required to follow the prudent layperson rules. HCFA has made it clear in
several letters to all Medicaid agencies that there are no exemptions from
the prudent patient guidelines, even in those states that have received
Hope this helps.
Jeff Linzer Sr, MD MICP
Division of Emergency Medicine
Children's Healthcare of Atlanta at Egleston and
Hughes Spalding Children's Hospital
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On Mon, 12 Jun 2000, Martin Herman wrote [snip]:
> 1. Who has to provide the MSE, MD?,NP?RN?
> ( we have used a triage system for the past 15 years or more, staffed by
> RN's who undergo 80 hours of training, and must have at least 6 months ED
> experience, would they be qualified to do the MSE?)
> 2. What will billed for the MSE?
> When is it appropriate to bill the E&M codes and when will the billing be
> limited to just the MSE ( and does a code exist for an MSE?)
> ( recognize that an MSE can require any or all of the services available at
> the hospital to establish that a) a medical emergency exists and b) that the
> patient is stable for transfer or disposition )
> Thanks for your input..
> Martin Herman,M.D., FACEP,FAAP
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