Yup, He's Dead
So we were enjoying one of the "not so busy" interludes that have become increasingly uncommon lately, when we got a call from an ambulance crew en route to our ER. An elderly gentleman had been picked up from a local nursing home with agonal respirations. Fortunately, either he or his loving family had the foresight to sign an advance directive well in advance which declared that he was not to be intubated or suffer the useless indignity of advanced cardiac life support.
However, he stopped breathing on the way to the ER, and according to the paramedics his heart rhythm was as flat as a Texas highway. So they were calling us for advice.
"How about taking his body back to the nursing home?" we suggested.
The nursing home refused to accept him back. So we were forced to generate a chart (and in the process, a bill) for a patient who wasn't really a patient at all anymore. Still warm, but pulseless, apneic, and without any trace of cardiac activity. His asystole was so flat that I jiggled the lead for a second to make sure that it was actually connected, fooling the nurse into thinking he had a brief moment of fibrillation. Sorry about that. Time of death, 0945.
And despite the time that I spent on phone calls and paperwork, I couldn't bring myself to bill for the encounter. It just didn't seem right. The family will already get a bill for the unnecessary ambulance ride, the ER facility fee, and the funeral expenses. I'm not going to charge them more for someone else's mistake.
However, he stopped breathing on the way to the ER, and according to the paramedics his heart rhythm was as flat as a Texas highway. So they were calling us for advice.
"How about taking his body back to the nursing home?" we suggested.
The nursing home refused to accept him back. So we were forced to generate a chart (and in the process, a bill) for a patient who wasn't really a patient at all anymore. Still warm, but pulseless, apneic, and without any trace of cardiac activity. His asystole was so flat that I jiggled the lead for a second to make sure that it was actually connected, fooling the nurse into thinking he had a brief moment of fibrillation. Sorry about that. Time of death, 0945.
And despite the time that I spent on phone calls and paperwork, I couldn't bring myself to bill for the encounter. It just didn't seem right. The family will already get a bill for the unnecessary ambulance ride, the ER facility fee, and the funeral expenses. I'm not going to charge them more for someone else's mistake.
Labels: death, ER, getting old, patients
posted by scalpel at 1:15 PM
16 Comments:
Nice call.
Honest procedural question: how can you choose not to bill? Your input was mandatory to call TOD, so I'm wondering if there's some check/audit by the billing system that will flag the fact that no physician-related code was present.
I just didn't click on a billing code, and our EMR doesn't require me to do so. Someone may decide to code my chart differently after the fact, but I didn't personally bill the patient (or Medicare).
Given the EM caveat for an unresponsive patient unable to provide a history or answer a review of systems, I could probably have coded a 99285 (level 5), but I chose not to.
that's an interesting story. i've never thought about what happens (administratively) when a patient dies en route to the ED. i still have much to learn.
Very thoughtful scalpel.
Where I work, they'd do one round of drugs, and shock 360, THEN call the code. Never seen a DOA, they're ALL DAA.
Where I am I think it is possible for the MD to call it and then they would just have the coroner respond to where the ambulance was
Medicare's policy is that benefits are terminated at the moment of death, so if your documentation indicates that the patient was dead on arrival, or died en route to the hospital, they will reject your bill anyway (in which case you and the facility are prohibited from billing the family).
The ambulance ride will probably get billed, though.
The official time of death was a couple of minutes after his arrival.
In reality, many of the codes that come in have died long before we stop working on them (and usually prior to their arrival), but we bill them all the same, not declaring them officially dead until after our attempts to resuscitate them have ceased.
I sometimes feel bad about billing those cases too, but not bad enough to not do so.
We just got a bill for FIL for $1,600.
He had a similar travel path/circumstance from nursing to ER. It seemed like a lot for someone who was dead, but they did keep him in the morgue for a day and got somebody to sign the death certificate. Death, taxes, health bills -- the only certainties in life!
BCBS paid their part - I assume the $1,600 was rung up before they pronounced him.
That was the right thing to do. Interesting story, too.
I've said it before, Scalpel, you're one of the good guys.
Call me a cynical bastard, but if the patient is declared dead in the hospital, the nursing home collects benefits until the end of the month. If he's declared dead in the nursing home, benefits cut off that day.
That may have had something to do with it.
Is it common for doctors to decide not to bill for their time? My insurance said that they cover the ER, but not the doctor at the ER. I never get a bill from the doctor. Do they REALLY like me, or is this a common practice?
I mention another example of how the time of death really means something. My pedestrian patient was hit by a vehicle very near the hospital. The paramedics found triple zeros, and transported. We worked him and then pronounced him a few minutes after midnight.
His wife returned months later to clarify the time of pronouncement. He had a life insurance policy that went into affect that midnight and the life insurance company was refuting.
My son 9, died unexpectedly of an apparent arrhythmia. he passed out at school, school staff started CPR, and an ambulance was dispatched, they were doing cpr in the ambulance when it arrived almost 30 minutes after he went unconscious. They called TOD about 10 mins or so at the ER. Worst day of my life.
Nobody was able to save him, just got the ambulance bill for 1200 bucks and 11 miles. Nothing more indignant than getting the bill a month later. I know everyone's gotta get paid, but it sucks none the less.... should have rolled the costs up with the funeral home... That would have made it a bit more palatable.
If you dont document and exam, your service isnt billable anyway.
I am sorry for the loss of your son ebayer, what a horrible tradgedy.
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