Appropriate Use of the Emergency Room 101

first-aid-1146983_960_720Have you recently been to the ER? What for? If you faced a true medical emergency, then you used the emergency room resource appropriately.

The list below will show a number of appropriate reasons for visiting the Emergency Department.

Please note: If you are in an emergency, call 911. You should call your PCP, a nurse hotline if you need medical advice. This article is not meant to be used as a means to diagnose any medical condition – only a qualified medical practitioner, such as a doctor, can help you to determine this. This article gives loose examples of situations that may warrant a visit to the ER: please use your best judgement in your prudent lay understanding of health and medicine.

 

Open Wounds & Active Bleeding

Did you get an open wound injury? Are you actively bleeding?

 

Allergic Reaction

Did you eat something that you shouldn’t have? If you have swelling, hives, or any other allergic reaction to the food you ate or some other element, it’s a good bet you should go to the ER.

 

Sudden Illness

Did you suddenly feel dizzy or short of breath at school or work? Sudden onset illness can be an indicator of a more serious condition.

 

Altered Behaviour

Are you or someone acting very strangely from their normal behaviour? For example: slurring words, unable to speak coherently or at all. It could be a sign of something more serious.

 

Abuse & Assault

If you have been assaulted or abused, please go to the ER immediately.

 

Threats of Abuse

If you are being threatened with physical or sexual abuse, call 911 or go to a police station.

 

Sports Injuries and Motor Vehicle Accidents

Were you in a sports related incident? Were you in a car accident? These are all reasons to go to the emergency room for a checkup for broken bones and other injuries. Even if you feel fine right after the incident, it’s good to go to the ER for a checkup. People who don’t go to the ER immediately can sometimes exhibit more post-accident conditions days later and so should also go to the ER.

 

Seizures

Anyone who is going through a cataleptic event or just did should go to the ER for a checkup as soon as possible. During a seizure a person can get further injuries that can and should be prevented.

 

Sudden and/or Severe Headache

A headache may not seem like an emergency to some, but they can be dangerous to people operating a car. If you are experiencing a very severe headache (worst in your life-type), then you should go to the ER. Sudden onset headaches are also serious and should be checked on by a doctor. If a headache has been moderate but chronic, spanning weeks and alternating in intensity – this could also warrant a visit to the ER and followed up with your PCP.

 

Torn Stitches and Medical Devices

Any stitches that have torn or medical devices that have been dislodged? You should be brought to the ER where a doctor or nurse can assist.

 

Severe Burns

If you have a severe burn, please go to the ER immediately.

 

Foreign Object

Children who have swallowed marbles, pennies and any kind of foreign object should go to the ER. Adults who have a foreign object should also go to the ER for help.

 

Severe Constipation / Urinary Issues

If your body isn’t working the way it should and you’re feeling heavy and ill from not being able to go to the bathroom, this is a very severe condition needing emergency attention.

 

Abnormal Bleeding

Ladies who have severe bleeding that is out of the ordinary for them, or any other urinary dysfunction.

 

Illness in Infant or Premature Infant

If your baby is ill and you have no other means to get health care, it is okay to bring your baby in. Premature infants should especially be brought in as they may be more susceptible to illness.

 

Unwitnessed Falls (Infants and Elderly)

Any fall or other injury that may or may not have occurred out of the sight of the parents or caregivers should be brought to the ER.

 

Vomiting

If you are very ill and continue to vomit without getting better, it is time to see the ER.

 

Severe Abdominal Pain – Stomach Pain

If you are experiencing severe sharp pains in your stomach region, then it is worth checking it out at the ER. Sometimes it can be the stomach flu, but it is worth checking.

 

Numbness

Anyone experiencing numbness of limbs, vision loss or alteration of vision, loss of feeling should go to the ER.

 

Severe Withdrawal

If you are addicted to any drug that is causing painful withdrawal, you should go to the ER for assistance. They may be able to redirect you to resources or help you there.

 

Chronic Conditions Exacerbated

Anyone with a chronic condition that has suddenly worsened should go to the emergency department for care. Whether that’s back pain or a recent rash, if it has gotten worse – go.

 

Self Harm

Anyone causing or considering causing injury to themselves should come to get care at the ER. They will be able to provide assistance and protection to you.

 

Shortness of Breath, Faintness and Dizziness

An alteration to your breathing, such as shortness of breath, faintness, fainting, dizziness and giddiness all need to go to the ER. They can be symptoms of a more serious condition.

 

Conclusion

The list above has broadly illustrated a set of situations where it may be appropriate to visit the Emergency Department. However, there are many more cases where you should go to the ER. How can you tell if it is a true emergency? Make your best judgement of the situation and get care. If you aren’t sure you may need medical advice – your PCP may have their line available, give them a call. Another option is a nurse hotline, where a certified trained nurse can help determine if you need to go to the ER right away.

Please use your best judgement in your prudent lay understanding of health and medicine.

  • “Would I suffer loss of life or limb if I didn’t go to the ER?”
  • Seek medical advice from a qualified medical practitioner, a doctor or nurse for example.
  • Call a nurse hotline if needing advice.
  • Sign up for PrudentLay.org Updates:



What is a Prudent Lay Person?


Definition

A Prudent Lay Person (or Layperson, abbreviated PLP) is a standard for deciding if an Emergency Room visit is necessary and presenting condition(s) of the patient reasonably warrant immediate attention.

The standard defines an emergency as a condition that a prudent lay person, “who possesses an average knowledge of health and medicine” expects, may result in:

1. Serious medical harm, or:

2. Serious impairment of bodily function, or:

3: Serious dysfunction of any bodily organ.

Prudent Layperson standard laws were “spurred by incidents of patients with genuine acute illness who delayed care for fear of being stuck with the hospital bill, said John C. Nelson, MD, president-elect of the American Medical Association.” (Amednews.com)

 

Profession

In some states like Oregon, there is a profession called the Prudent Lay Reviewer or Prudent Person, created for the evaluation of Emergency Room claims based on the PLP standard. It is a health insurance occupation.

The Prudent Lay reviewer “possesses an average knowledge of health and medicine” fulfilling the Prudent Layperson standard (McGraw-Hill Concise Dictionary of Modern Medicine, 2002). Their average knowledge helps them to apply the Prudent Lay Standard to ER claims payment decisions.

The prudent lay profession is uncommon. Certain state(s) employ the prudent lay professional, but many still don’t.
No prudent layperson profession in some states.

Typically Emergency Room claims payment is based on a pairing of CPT codes (99281, 99282, 99283, 99284, 99285) and the Diagnosis code for the ER visit, using partially or fully automated adjudication software. These systems may not perform a comprehensive review of the ER claim based on the Prudent Lay standard, so claims over-payment results due to upcoding and mistakes on the part of the claim-submitting provider.

 

What does a Prudent Lay Person do?

A Prudent Lay Person (or ‘Prudent Lay Reviewer’) looks over Emergency Department chart notes to determine whether the emergency room visit was a “true medical emergency” requiring full reimbursement by the health insurance company. In almost all cases, the ER claim will be paid some amount.

The PLP reviewer can issue a lesser payment to a health care provider, such as a hospital or ER clinic, if the ER visit was not a true medical emergency (a mild “cough”, a “general health checkup”).

A greater amount can be issued based on the PLP reviewer’s decision, if it is indeed a true medical emergency warranting immediate attention in the Emergency Department (“motor vehicle accident”, “shortness of breath”, “chest pain”, “sudden allergic reaction”).

It is a profession which requires case by case evaluation of ER claims based on documentation of the Emergency Room visit. The documentation provided is used by the reviewer to make a determination on the amount paid on each ER claim.

About payment of ER claims: Health insurance companies are required to pay all ER claims. But in certain states, there is a lesser amount called Pay Triage, or some variation of the term, meaning, “the lesser amount”. This lesser amount may be paid by health insurance companies. There may be different rules in your state.

You can learn more about the term ‘Triage’ here: History of Triage on Wikipedia

 

How ER Claims are Reviewed by a Prudent Layperson Reviewer

The one element that weighs most heavily on a PLP reviewer’s decision is 1) documentation and 2) the perceived severity of the initial condition from the standpoint of the patient.

Last, the Prudent Layperson reviewer will often ask “Would I, possessing an average knowledge of health and medicine, go into the Emergency Room for this condition?”, in order to make a final ER claims payment decision.

 

Prudent Lay Review Decisions are based primarily on:

1) Chart notes: The most critical element in a prudent lay review decision is the detailed description of the Emergency Room event found in the History of Present Illness note, a standard description of prior conditions and the patient’s reason(s) for going to the Emergency Room. The initial presenting symptoms are the most important detail weighed by the PL reviewer within the HPI.

2) The initial symptoms and the patient’s perception of the severity of the emergency room visit, as well as their charted behavior.

3) The Prudent Layperson Reviewer’s own best judgement: “Would I, possessing an average knowledge of health and medicine, go into the Emergency Room for this condition?”

Note: Health insurance companies may employ different review structures, however, if the Prudent Lay standard is being used as the template for ER claims reviews, then initial presenting symptoms will be the primary element used on a claims payment determination, wherever the PLP reviewer positions exist.

 

What kind of decisions do Prudent Layperson Reviewers make?

Full payment of an Emergency Room claim
Partial or Lesser payment of an Emergency Room claim *
Request for additional chart notes from the provider on an Emergency Room claim
Denial of an Emergency Room claim for not meeting one or a set of state requirements, such as timely filing of claim *
* Different state rules: Not all states have the same guidelines and rules.

 

Why is the Prudent Lay Person Profession necessary?

In certain states, a health insurance company may employ a Prudent Layperson reviewer in order to review the medical necessity of ER visits and issue appropriate payment of ER claims, based on the PLP standard set by State and Federal government, as defined earlier in this article.

Do all states have a Prudent Layperson Reviewer Profession?
No. However, the Prudent Layperson standard itself is widespread and growing in popularity.

In states where the Prudent Lay Person standard is in effect, Emergency Room claims may be reviewed case by case. But this is not always so with health insurance companies.

You can learn all about Prudent Lay Person standard here on PrudentLay.

 

How do you become a Prudent Layperson?

To be a prudent person, you must possess an average knowledge and understanding of health and medicine. If you are in the medical profession, chances are you have an above average understanding and knowledge of health and medicine which makes you overqualified for a position such as this.

If you wish to apply for a Prudent Layperson position at a local health care company, you can look at websites like Monster.com or inquire on their hiring or contact page. For other positions, click here.

What happens when a Prudent Layperson exceeds average knowledge of health and medicine?
As soon as a person employed in the review of Emergency Room chart notes has exceeded the average understanding of health and medicine, it is time for them to change positions.

The purpose of the role is that the PLP exercise the same type of judgement (or at least close enough) to an average ER utilizer. When this individual no longer fits the definition, their decision making may become more lenient toward the symptoms, diagnoses, and hospital work-up as noted in the ER chart notes.

However, the PLP profession calls for an evaluation based not on diagnoses or the medical opinion of the physician, but on the initial presenting symptoms of the Emergency Room patient.

 

Does the Prudent Person Standard save the state money?

Think of this scenario:

Hospitals and clinics bill emergency room codes, called CPT codes 99281 through 99285. These codes are based on the severity of the visit, the 1 being the least urgent and the 5 being the most critical, near fatal event.

When a nurse, nurse practitioner, physician or even a medical assistant writes up the chart notes, they may inadvertently over emphasize the degree of symptoms. Perhaps intentionally they will do so at times.

The medical coding professional will then evaluate the chart notes and determine the severity CPT code. They may assign a level 5 urgency for an event that was actually a mere 2 event.

When the proprietary adjudication system (software that processes ER claims based on a variety of codes and the CPT code) runs a thousand claims through its decision making algorithms, it will not always make the best of decisions.

It may take that 99285 code with more valence than the note within the charts that state the patient was in no acute distress, laughing and enjoying themselves in the ER.

This is where the Prudent Layperson profession comes into play: it would eliminate a good deal of claims that are up-coded unnecessarily and that pay out far more money on a hospital visit than they should.

 

You may be interested in the following references:

Feature Image Attribution: Mendolus Shank (CC)

What is a Prudent Layperson?

Definition
A Prudent Lay Person (or Layperson, abbreviated PLP) is a standard for deciding if an Emergency Room visit is necessary and presenting condition(s) of the patient reasonably warrant immediate attention.

The standard defines an emergency as a condition that a prudent lay person, “who possesses an average knowledge of health and medicine” expects, may result in:

1. Serious medical harm, or:

2. Serious impairment of bodily function, or:

3: Serious dysfunction of any bodily organ.

The standard was first enacted in 1992, “spurred by incidents of patients with genuine acute illness who delayed care for fear of being stuck with the hospital bill, said John C. Nelson, MD, president-elect of the American Medical Association.” (Amednews.com)

You can learn even more here: PrudentLay: What is a Prudent Layperson?

“Prudent layperson standard.” McGraw-Hill Concise Dictionary of Modern Medicine. 2002. The McGraw-Hill Companies, Inc. 6 Jul. 2015

What is Prudent Lay?

What is Prudent Lay?
Prudent Lay Person is an individual defined as having a limited understanding of medicine and health, thus they are deemed a “lay person” – this is where the Lay part of Prudent Lay comes from.
This occupation was created in order to ensure Emergency Room (Emergency Department) claims to providers were being paid based not on the medical condition or the diagnosis of the physician but on the perceived necessity of an “average” person with limited medical knowledge. It is not based on the final condition of the member’s visit – rather it is based on the presenting symptoms and how critical they are perceived to the member.

This website is to educate and inform physicians, nurses, insurance companies and the general public regarding the Prudent Lay Person Standard and the Prudent Lay Person profession.

Where do Prudent Lay people work?
Primarily a prudent lay person is employed in health insurance companies. Since the title is unusual, many people are often curious about its origin.

Welcome to The Complete Reference to The Prudent Lay Profession – PrudentLay
Cited from Pugetsound.va.gov:

The Prudent Layperson Fact Sheet:
“In 1986, Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA) governing the provision and payment of emergency medical services in Medicare participating hospitals. In 1994 a revision to the act added the “prudent layperson” definition as a standard for evaluating whether a patient has an emergency condition. The Balanced Budget Act of 1997 established the “prudent layperson” standard for Medicaid effective October 1997 and the same standard became effective for Medicare in May 1998. The Department of Veterans Affairs adopted the standard in November 1999 when the Veterans Millennium Health Care and Benefits Act prescribed the “prudent layperson” standard for evaluating emergency care as one of the criteria for authorization and payment of emergency treatment for nonservice-connected conditions. The prudent layperson definition of an emergency medical condition commonly in practice is any medical or behavioral condition of recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in placing the patient’s health in serious jeopardy, cause serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy. This prudent layperson definition of emergency medical condition focuses on the patient’s presenting symptoms rather than the final diagnosis when determining whether to pay emergency medical claims. Note: Under the prudent layperson standard payment for emergency care is made for the initial evaluation and examination based upon the nature of the patient’s presenting complaint. Payment may be made for additional medical services until the condition is no longer clinically determined to be emergent in nature and the patient is stable for transfer to VA or discharge.”
If you have any additional questions about this unusual profession, please contact us.

On our website you may be able to locate a job in this profession:

Find a Prudent Lay job in your city
Find a Prudent Lay job in your state

What is the Prudent Man Rule?

This legal definition is for disambiguation purposes only, and is not related to the Prudent Layperson Standard in health care. However, as a courtesy, we provide this term here as it contains a common search phrase that people seek:

“Prudent Man Rule is an investment standard. It directs trustees “to observe how men of prudence, discretion and intelligence manage their own affairs, not in regard to speculation, but in regard to the permanent disposition of their funds, considering the probable income, as well as the probable safety of the capital to be invested”. [Harvard College v. Armory 9 Pick (26 Mass) 446, 461 (1830).]

In some states, the law requires that a fiduciary, such as a trustee, may invest the fund’s money only in a list of securities designated by the state,the legal list. In other states, the trustee may invest in a security if it is one that would be bought by a prudent person of discretion and intelligence, who is seeking a reasonable income and preservation of capital.”

SOURCE: Legal Definitions of Prudent Man, Prudent Man Rule

10 Non-Urgent Reasons People Go To The Emergency Room for Care: Waste in Health Care

Here are a few reasons people go to the ER for Non-Urgent health care issues – this list is not made up, it is based on real ER visits. Some of these types of visits are very common. Others are less common, yet show up frequently enough that they are worth a mention due to their non-emergency nature:

  • To get primary care instead of going to their doctor.
  • To get the entire family a general health checkup.
  • To get a prescription which they lost or used up – in cases for minor health conditions.
  • To get pain or other medications to sell them illegally.
  • To get a “back to work” slip.
  • To sleep in the ER because it is cold outside.
  • To remove a piercing or tight fitting ring.
  • To get a second opinion on a primary care-type health condition.
  • To get a pimple checked out.
  • For a mild cough but otherwise completely healthy.

 

What is the take-away?
Don’t use the Emergency Room for Non-Urgent reasons.

A mild cough is usually not an emergency. Your body may be able to heal itself. If you have comorbid or chronic conditions that are exacerbated by a cough, then it may be a true emergency.
A heart attack, shortness of breath, chest pain and other conditions are the types of conditions that qualify as a true medical emergency.

What is an emergency to you?

Please talk about these things at home and at work to help reduce overutilization of the Emergency Department for minor or mild, Non-Urgent health conditions. ER visits are very costly to your state.

 

Wait times in ER’s across the country

Based on data averages – Interactive wait times tool by ProPublica.org. Last updated: Jan. 14, 2015

ER Wait Times

SOURCE: ER Wait Watcher via ProPublica.org

Wait Times Increase in ER
“Research from Press Ganey Associates, a group that works with health care organizations to improve clinical outcomes, finds that in 2009, patients admitted to hospitals waited on average six hours in emergency rooms. Nearly 400,000 patients waited 24 hours or more.”

SOURCE: Don’t Die Waiting in the ER – 2009 CNN

RELATED ARTICLES:

“Wait Times Soar” Daily News
“Waiting for the Emergency Room” AFB
“Patients and Doctors Struggle with Wait Times” DAM
“A Bold Guarantee” Mequon Now
Ambulatory Health Care Data – CDC survey

Wait times in Urgent Cares across the country:
“Sixty-nine percent of urgent care centers have wait times of less than 20 minutes, 28 percent have wait times between 21 and 40 minutes and 3 percent have more than a 40 minute-wait.1″

SOURCE: 25 Things to know About Urgent Care – Beckers Hospital Review

Wait times for a Primary Care Physician’s appointment:
PCP Wait Time In Days National Average 2013
Cumulative Average Wait Time in Days, 2013

Cumulative Average Wait Time in Days, 2013
Cumulative Average Wait Time in Days, 2013

About 19 days waiting to see a Primary Care Physician after scheduling an appointment, national average in 2013. Based on a study of 1,400 medical offices in the United States. This means Wait Time in Days for a PCP appointment/specialist may have actually decreased slightly since 2009, by about 2 days.

PCP Wait Time In Days National Average 2013 Part B
Cumulative Average Wait Time in Days, 2009 and 2004
SOURCES: Merritt Hawkins: Physician Appointment Wait Times and Medicaid and Medicare Acceptance Rates (PDF report), Doctor Wait Times Rise As ObamaCare Rolls Out, NY Times: Long Wait Times Have Become the Norm

Attribution: Eric Lewis (CC)

Preventable ER Overutilization: Questions That Could Be Asked BEFORE Triage

Questions that triage nurses could gently ask before triage to save the state money and reduce non-urgent usage of the ER:

1. Have you contacted, or been to your PCP for your health/medical conditions?
If the member says no and has a low urgency event, they could be redirected easily before costing the hospital money.

2. Have you gone to Urgent Care?
If the member says no and has a low urgency event, they could be redirected easily before costing the hospital money.

3. Do you know about these resources [ provide a list of free non-urgent resources, including Urgent Care ]?
If the member says no and is redirected to a helpful resource, and has a low urgency event, they could be redirected and save the state and tax payer’s money and the hospital’s time, money and ER space.

What may be happening today in ER’s:
Hospitals and ER clinics have non-urgent visits triaged instead of deferring them prior to triage.

The result is, the hospital or clinic gets additional revenue from many non-urgent visits that could have been properly redirected (deferred) to free resources and outreach programs.

The Pressures in the Emergency Room
Nurses and physicians have to deal with a lot of troubled, sick people in the Emergency Department.

They don’t always have the right answer and there are a lot of pressures.

With a little training, every ER in the United States can properly redirect low-urgency visits and reduce needless overutilization:

Here is a video interview of a nurse sharing a day in the life of an ER nurse:

Attribution: Sean Hobson (CC)

Emergency Room Billing CPT Codes 99281 – 99285

What is a CPT 99281 code?
It is a commonly used definition of an Emergency Department visit and is used in medical billing.

A 99281 CPT code is a visit that has three main components:

A problem-centric history.
A problem-centric exam.
Very simple medical decision making.
Usually, the symptoms the patient presents with are low urgency, requiring little to no immediate medical care. Some of the symptoms that fit under the 99281 code are self-treatable.

This low severity Emergency Room visit requires the least comprehensive chart notes.

What is CPT 99282 code?
It is a commonly used definition of an Emergency Department visit and is used in medical billing.

A 99282 CPT code is a visit that has three main components:

A longer problem-centric history.
A longer problem-centric exam.
Simple medical decision making.
Usually, the symptoms the patient presents with are low to moderate urgency, requiring low to moderate medical care. The severity is usually moderate to low. Some of the symptoms that fit under the 99282 code may not be self-treatable.

This low to moderate severity Emergency Room visit requires slightly more comprehensive chart notes.

What is CPT code 99283?
It is a commonly used definition of an Emergency Department visit and is used in medical billing.

A 99283 CPT code is a visit that has three main components:

A longer problem-centric history.
A longer problem-centric exam.
Moderately complex medical decision making.
Usually, the symptoms the patient presents with are moderately severe and urgent, requiring immediate care.

This moderate severity Emergency Room visit requires more comprehensive chart notes.

What is CPT code 99284?
It is a commonly used definition of an Emergency Department visit and is used in medical billing.

A 99284 CPT code is a visit that has three main components:

A detailed problem-centric history.
A detailed problem-centric exam.
Moderately complex medical decision making.
Usually, the symptoms the patient presents with are of high severity, requiring immediate care but “does not pose an immediate significant threat to life or physiologic function”.

What is CPT code 99285?
It is a commonly used definition of an Emergency Department visit and is used in medical billing.

A 99285 CPT code is a visit that has three main components:

A high detail problem-centric history.
A high detail problem-centric exam.
Highly complex medical decision making.
Usually, the symptoms the patient presents with are of the highest severity, posing an immediate significant threat to life or physiologic function.

SOURCE: CPT 2011, CPT Assistant

Under Obamacare Er Costs Actually Increased

Based on 2011 data by the Health Cost Institute (PDF), the average cost of er visits increased by 5%, to about $1,381 per emergency room visit.

That is about a month of rent for some Americans. It remains above $1,000 per visit (average) nationally. This is much more than an average Primary Care visit to the doctor.

However, in the Obamacare health care paradigm, the frequency of er visits is increasing.

Why? PCP’s may be turning down patients because the Obamacare health plans don’t give a high enough reimbursement to physicians and clinics.

ER Costs
The above table by CareFirst.com compares Urgent Care costs versus Er costs, based on presenting symptoms.

A 2015-typical emergency room visit for a cough shouldn’t cost $1000, but the resources needed to run an emergency room department often require these charges: ER’s are equipped with modern technology, 24/7 nurse and physician staff that is specially trained for acute emergent situations, not to mention security staff for protection of patients, visitors and staff.

But there are even more startling developments regarding er costs that would shock most people:

There is a huge variation in the cost of each er visit: “Bills sent out for sprained ankles ranged from $4 to $24,110,” according to a report by the Washington Post.