Master the upcoming ICD-10 code and IPPS changes! Prepare your team for the upcoming changes taking effect on October 1. Discover the benefits of IPPSPalooza and how it can drive your success. Click here >

Can a “Prudent Layperson” Really Recognize an Emergency Medical Condition?

Documentation is integral to solving this problem.

UnitedHealthcare (UHC) recently threatened to implement a new policy wherein they would be retroactively denying some emergency department claims for their commercial members if an internal evaluation suggested that the services were not emergent. Anthem has had a similar policy in place since 2018. In fact, over the years, many insurers have attempted to deny emergency care retrospectively. UHC decided to delay implementation until the end of the national public health emergency (PHE) period.

The Patient Protection and Affordable Care Act (PPACA) requires insurance companies to cover care provided in the emergency department if you have an emergency medical condition. Herein lies the rub. As anyone who works in an emergency department can attest to, not all patients who present to the emergency department, in the final analysis, have a condition necessitating emergency treatment. Case in point: I distinctly remember doing a pretty comprehensive work-up on a patient for cyanosis who ultimately turned out to have new jeans dyeing her skin.

The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law enacted in 1986 requiring anyone presenting to an emergency department be stabilized and/or treated regardless of ability to pay (https://www.acep.org/administration/reimbursement/reimbursement-faqs/emtala-and-prudent-layperson-standard-faq/#question3). The EMTALA definition of an emergency medical condition is “a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health (or the health of an unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.”

This is the basis of the Prudent Layperson Standard, which essentially says that if a “prudent layperson” who possesses an average knowledge of health and medicine might believe that the symptoms present might lead to serious consequences without immediate medical attention, that would constitute a bona fide emergency medical condition. In 1997, Congress enacted the Prudent Layperson Standard for Medicare and Medicaid managed care plans, and it has been expanded to include other populations.

The emergency medical condition, the admitting diagnosis, may differ from the final discharge diagnosis. If you have ever had seriously bad abdominal cramps, you can imagine that a layperson might not be able to distinguish gas pains from a bowel obstruction at the onset of symptoms. It is not fair to penalize the healthcare system.

I remember early in my attending career admonishing a youthful trainee who was denigrating an inexperienced young mother who carted her 2-year-old into the emergency department for a fever, rather than calling the pediatrician three hours later. I explained that the toddler had probably been crying for six hours straight due to excruciating ear pain from an ear infection. Is otitis media a legitimate emergency medical condition?

As always, I believe that documentation is integral to solving this problem. The medical record needs to demonstrate that this prudent layperson, when seeing blood, couldn’t judge whether stitches were required – “the patient states that the wound was bleeding briskly.” That young mother reported that “her child has been inconsolable and crying since 10 p.m.” Even a patient with tolerable pain may present to the emergency department because “I had a headache just like this with my first stroke.”

One could consider modifying the documentation template. Instead of calling the presenting problem “the chief complaint,” it might be framed as the “reason why the patient presented for emergency care.” However, in the final analysis, the provider should document what the patient’s motivation, fear, or perceived risk was that elicited their visit – even if at the end of the encounter, they were deemed safe for discharge.

Emergency medicine documentation has multiple boxes to tick. It needs to meet medical necessity for both being seen at all, and for justifying the status determination. It needs to establish present-on-admission diagnoses. It must address medicolegal concerns. It needs to demonstrate severity of illness and risk of mortality. A few adjectives and explanations can be the difference between reimbursement or denial for an inpatient stay.

In response to the threatened-but-temporarily-rescinded unfair denial policy, I was hired by an organization to create a presentation to teach principles of excellent documentation in the emergency department. I’d be happy to present it to your department, too. Feel free to contact me at icd10md@outlook.com.

Programming Note: Listen to Dr. Erica Remer when she co-hosts Talk Ten Tuesdays with Chuck Buck, Tuesdays at 10 Eastern.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn
Email
Print

Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

The CMS Two-Midnight Rule and short-stay audits are here to stay, impacting inpatient and outpatient admissions, ASC procedures, and Medicare Parts C & D. New for 2024, the Two-Midnight Rule applies to Medicare Advantage patients, requiring differentiation between Medicare plans affecting Case Managers, Utilization Review, and operational processes and knowledge of a vital distinction between these patients that influences post-discharge medical reviews and compliance risk. Join Michael G. Calahan for a comprehensive webcast covering federal laws for all admission processes. Gain the knowledge needed to navigate audits effectively and optimize patient access points, personnel, and compliance strategies. Learn Two-Midnight Rule essentials, Medicare Advantage implications, and compliance best practices. Discover operational insights for short-stay admissions, outpatient observation, and the ever-changing Inpatient-Only Listing.

Print Friendly, PDF & Email
September 19, 2023
Secondary Diagnosis Coding: A Deep Dive into Guidelines and Best Practices

Secondary Diagnosis Coding: A Deep Dive into Guidelines and Best Practices

Explore comprehensive guidelines and best practices for secondary diagnosis coding in our illuminating webcast. Delve into the intricacies of accurately assigning secondary diagnosis codes to ensure precise medical documentation. Learn how to navigate complex scenarios and adhere to coding regulations while enhancing coding proficiency. Our expert-led webcast covers essential insights, including documentation requirements, sequencing strategies, and industry updates. Elevate your coding skills and stay current with the latest coding advancements so you can determine the correct DRG assignment to optimize reimbursement, support medical decision-making, and maintain compliance.

Print Friendly, PDF & Email
September 20, 2023
Principal Diagnosis Coding: Mastering Selection and Sequencing

Principal Diagnosis Coding: Mastering Selection and Sequencing

Enhance your inpatient coding precision and revenue with Principal Diagnosis Coding: Mastering Selection and Sequencing. Join our expert-led webcast to conquer the challenges of principal diagnosis selection and sequencing. We’ll decode the intricacies of ICD-10-CM guidelines, equipping you with a clear grasp of the rules and the official UHDDS principal diagnosis definition. Uncover the crucial role of coding conventions, master the sequencing of related conditions, and confidently tackle cases with equally valid principal diagnoses.

Print Friendly, PDF & Email
September 14, 2023
2024 IPPS Summit: Final Rule Update with Expert Insights and Analysis

2024 IPPS Summit: Final Rule Update with Expert Insights and Analysis

Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY24 Inpatient Prospective Payment System (IPPS) Final Rule, including new ICD-10-CM/PCS codes, plus insights, analysis and answers to questions from the country’s most respected subject matter experts.

Print Friendly, PDF & Email
2024 IPPS Summit Day 3: MS-DRG Shifts and NTAPs

2024 IPPS Summit Day 3: MS-DRG Shifts and NTAPs

This third session in our 2024 IPPS Summit will feature a review of FY24 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by senior healthcare consultant Laurie Johnson, with bonus insights and analysis from two acclaimed subject matter experts

Print Friendly, PDF & Email
August 17, 2023

Trending News