October 11, 2018

Rants, Raves and Reflection - Part One

In this edition

  • How costly can a dog bite be anyway? More than you think . . .
  • Don’t let your electronic medical record (EMR) destroy your career: Tell the truth, all the relevant truth, and ONLY the truth.
  • How would you feel about paying what you charge your patients?
  • Advanced practice providers (APPs) are not emergency physicians. Don’t pretend they are (or let them think that).
  • You are not paranoid ... you are being watched, so act like it. And (some) people may be out to get you.
  • Oral antibiotics and LET: What you thought you knew . . . but think again.
  • If it is an ED case, yes, EMTALA applies.

As a former ED medical director and (now) clinical informatisist, I have some things to say. You probably do too, so feel free to contribute to this newsletter. From time to time, I hope to offer some sage advice, along with a few pet peeves.

A large part of the role of medical director is to be aware and head off potential issues. When I became medical director of my group, I was amazed at how many things were occurring of which no one seemed to be aware. And I am sure I missed a lot of things, too. In this and future columns, I will address common issues and why you should care.

In addition, if you have not participated in the ACEP ED Directors’ Academy (EDDA), you are missing perhaps the single most beneficial educational program ACEP offers. Like many before, I learned mostly from the “School of Hard Knocks.” That is no longer necessary for current and future ED medical directors. Do not underestimate the value of this program and the ongoing benefit of the EDDA list-serve (largely an on-line Q & A).

Today’s Rant: ED EMR Documentation, Billing/Coding and APPs

NOTE: The following is loosely-based on a real case; unfortunately, you can’t make this stuff up. The purpose of this case study is to raise awareness of common issues. It is not to disparage EMRs or clinicians (APPs in this case). There are good and not so good ones everywhere.

Have you heard of “surprise-billing”? If not, read about it here. This case illustrates how EM may be its own worst enemy. In large part, “surprise-billing” relates to non-contracted providers. However, we must recognize that, due to high deductibles, copays, and co-insurance, all ED patients for the most part are “uninsured” (responsible) for the first $1000 to more than $13,000 of charges (first dollar coverage), even if they have insurance.

Case History

Dog Bite to the Face – How This Could Cost You a Million Bucks!

While visiting grandpa, a 16-month old female is bitten by his dog on the left cheek. No vital structures (eg, eyelids, mouth, nose, etc.) are involved. There are four puncture wound lacerations, 3mm, 3mm, 4mm, and 5mm = total 15mm. The child has not received any immunizations to date. There are no other injuries, other than surrounding bruising and abrasions. Grandpa takes her to a local ED, outside of insurance network. Note the family was with the child at all times during the ED visit and recorded their observations.

ED Care

The child is seen by an (unsupervised) APP, in this case a nurse practitioner (NP). A cursory exam is performed, topical anesthetic is (ineffectually) applied, wounds are cleaned, tissue adhesive is applied, then Steri-strips are applied over the dried adhesive. A dose of Augmentin is given in the ED, with a prescription for a 7-day course. Although noted as not up-to-date, no tetanus toxoid is given. Total time in treatment room is 20 minutes and arrival time to discharge is less than one hour.

Obvious Issues

  1. Tissue adhesive is contraindicated in the treatment of dog bites, and in this case, largely ineffective for cosmesis, likely due to incorrect application (perhaps fortunate, considering).
  2. Steri-strips fall off within about eight hours, as does about half of the tissue adhesive (see above).
  3. Tetanus toxoid is not offered\given (subsequently given by primary care physician (PCP) at follow up three days later).

Additional Issues After Chart Review


  1. Documented ESI level = 4. Triage nurse estimated lacerations to be 5cm total (grossly inaccurate).
  2. Total laceration length noted in the chart by the APP was 3cm (100% error) resulting from the fact the APP did not actually measure the wounds (confirmed by family). The difference in billing between 1.5cm (actual) and 3.0cm is significant.
  3. The APP appeared to have used an “adult” EMR documentation template, resulting in multiple (even comical) errors such as “Patient was awake, alert, oriented to person, time, place and surroundings” and “Psychiatric: Cooperative, appropriate mood and affect, normal judgment”, amongst other impossible observations in a 16-month old.
  4. The APP failed to actually perform an exam other than a brief look at the wounds, eg, documented the mouth was normal but never actually looked into the mouth (confirmed by family) to observe if the wounds were full thickness, possibly extending into the oral mucosa.
  5. APP stated, “Discussed in great detail options for closure with either 1 or 2 sutures to laceration versus Dermabond and Steri-strips. Parents agree that they prefer Steri-strips and Dermabond.” Family recalled a simple question, “Do you want stiches or glue?” The truth is probably somewhere in between, but regardless, from a standard of care perspective, the appropriate consideration was sutures or nothing, no matter how “detailed” the discussion.
  6. Immunization (tetanus) discussion was documented, but did not actually occur (confirmed by family).

It Gets Worse

About 12 hours after the ED visit, after the Steri-strips and Dermabond started to fall off, the child’s mother called an ED physician friend to ask what to do. At that point, since the window for primary closure had passed, nothing more could be done except to recommend a tetanus shot by the PCP on the following Monday.

Then the bill came ...

Before I go there, how would you have coded this encounter? 99281, 99282, 99283 ...? Obviously, the total length of the lacerations dictates the procedure charge. But, as a consumer, what do you think should be the total charges for this level of care? Consider both the “retail” and insurance discounted rate.

Billing Details

  1. Visit level was billed as a 99283, which might have been appropriate if the care and documentation supported it. For reference, Medicare pays ~$80. The charge was $930.
  2. The procedure was billed as “Wound Repair: Simple\Superficial”. CPT code was not provided, but likely 12013 for 2.6-5cm laceration repair, which for reference Medicare pays ~$230. Correct code should have been 12011 for laceration repair <2.5cm. The charge was $850.
  3. Ancillary Charges: $338 total
    • Augmentin (one dose) = $95
    • Dermabond = $135
    • Steri-strips = $10
    • Hexachlorophene soap = $18
    • LET topical anesthetic = $80

So, does $ 2,118 for billed charges pass the “sniff test”? For some reason (a national insurance carrier), the contracted discount was only 10%. So, the parents were out of pocket $1900. That’s roughly $3000 per hour (based on about 30 minutes patient care time) just for the provider. No EP was involved or consulted on the care.


For perhaps obvious reasons, ultimately the bill was written off, largely based on actions taken by an astute ED medical director. It is difficult to say, but the child may require scar revision at some point, as the opportunity to achieve optimal cosmesis was lost, due to inappropriate care.

What Can We Learn?

Fee schedules matter: I understand that we have a perverse system of “charges” because of inane CMS rules. That needs to change. But in the meantime, you should review your fee schedule in light of dramatic increases in out of pocket costs. I also understand that various demographic populations can impact what charges need to be, but they still need to be reasonable. Ask yourself what you can reasonably defend when a case such as this makes it to the local news media.

Insurance contractual rates: Again, with a shift in first dollar coverage, patients are impacted more than ever before by insurance contracts. Be sensitive to this impact.

“Surprise billing”: It is going to be difficult for emergency medicine to make their case on “surprise billing” if cases like this obfuscate the message.

EMR documentation: While perhaps a necessary evil, EMRs (ED Information Systems or EDISs) are here to stay. Like any tool, EDISs must be used appropriately. It is all too easy to “over-document”, due to auto-fill templates, and as this case illustrates, choose an incorrect template. A full treatment of this topic is beyond the scope of this article, but as part of your regular QA/CQI process, a certain percent of charts should be reviewed for “accuracy”. It is as easy to determine if charts are being overly “documented” as it is under-documentation. For example, are there routinely full ROS on virtually every chart, even those that do not require it (eg, 99281-99283)? Do you see “ROS: All other systems reviewed and are normal”? Just simply ask that provider to name all 14 systems. Most cannot. Ironically, the use of scribes has helped this issue, because they only document what they see and hear.

Provider qualifications: It would be difficult to imagine that a residency trained and/or board-certified EP would have made the treatment errors in this case, but we all make our fair share. The example here is a “knowledge error” (albeit rather rudimentary) vs. a “cognitive error” (more common with EPs). But the point being, if you use APPs in your ED, oversight is critical even for minor cases. APPs simply cannot be expected to have the same level of expertise as EPs. Amongst other things, APPs should be instructed that they must ask for supervision anytime they are unsure or the first few times they are faced with any particular condition. At this level, knowing what they do not know is super important. Knowing when not to do something is also more important than when to use it.

Giving first antibiotic dose: I will not argue the questionable necessity of antibiotics in this case, but as a resident, I was taught that giving the first dose of an antibiotic in the ED was standard of care. Now I am not so sure that is true, and it has significant financial implications. An outpatient pharmacy RX for Augmentin costs between zero (insurance) to $12 (retail). Charging almost 10X for one dose IMO is unconscionable. With ready availability of 24-hour pharmacies and proper instructions, allowing the RX to be obtained as an outpatient is perfectly reasonable. You at least owe your patients the courtesy of knowing how much it will cost.

LET (Lidocaine, Epinephrine, Tetracaine) or EMLA (Eutectic Mixture of Local Anesthetics aka lidocaine/prilocaine): One of the most underused and most inappropriately applied medications in the ED. LET takes about 20 minutes in an open wound and EMLA takes about an hour on normal skin to achieve an effect. EMLA has also been shown to be effective in lacerations1. So, if you do not have a protocol to apply these medications at triage, you are missing a huge satisfaction opportunity. Nevertheless, if they are used, they must be applied correctly, with direct contact to the subcutaneous surface (for lacerations) and wait time provided. Want to charge $80 for a treatment? It better work.

People are watching (documenting): There are many things to be learned from the flurry of recent sexual harassment allegations. Perhaps not so obvious is that things that sound true are likely to be taken that way. Another is everyone has a body camera and is willing to use it. When at work, you should behave as if you are being recorded. You may very well be. Now that patients are personally responsible for thousands of dollars for even relatively minor care, they are going to pay attention. Will your own documentation hold up to comparison to a recording?

Do not underestimate the resolve of your patients: Here is a list of potential adverse outcomes of this case with an estimate of what it might cost (settlement, attorney fees, fines, etc.):

  • Medical malpractice: $30,000-$50,000
  • Billing fraud: $25,000 to millions
    1. Includes over-documenting, false documentation, inaccurate documentation
    2. Whistleblowers (think disgruntled employees) can receive cash rewards of 15-30% of the money that Medicaid\Medicare recovers
    3. Disgruntled patients may report suspected activity to the insurer, state agencies (Dept. of Insurance, Attorney General, Medical Board, etc.) and CMS
  • Commercial insurance carriers: $25,000 to millions
    1. Healthcare insurers may cancel contracts or assess fines
    2. Medical malpractice carriers may cancel your coverage or charge you more
  • Regulatory boards (medical and/or nursing board): $25,000 to $50,000
    1. Documentation issues may be considered “unprofessional conduct” and subject to sanction by oversight boards: Medical (Allopathic) for MD and PAs\Osteopathic for DOs\Nursing Board for NPs
    2. Defending such can be expensive and result in multiple untoward consequences including loss of license
  • EMTALA: $102,000 per violation
    1. As most know, APPs in the ED must be designated as “Qualified Medical Providers” (QMP) by the hospital governing board in order to provide an EMTALA Medical Screening Examination.
    2. What some do not know is that this designation must be done on an individual basis. In other words, each individual person acting in this role must be reviewed by the governing board and designated (credentialed) as such. Merely having a designation in the hospital rules or medical staff bylaws that any PA/NP acting in the role as an APP are QMPs is not sufficient.
    3. There must also be evidence of sufficient training for such an individual to provide these services. A basic lack of knowledge demonstrated by gross malpractice could bring these qualifications into question. In other words, you can’t just put a psych NP in the ED and have them act unsupervised.

If you got to the end of this article, good for you. Now get back to work and stop wasting time reading. :) 


  1. Singer AJ, Stark MJ. LET versus EMLA for pretreating lacerations: a randomized trial. Acad Emerg Med. 2001 Mar;8(3):223-30.

Todd BTaylor, MD, FACEP

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