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.