In many institutions, patients assessed as likely to remain “ambulatory” and “treat-and-release” are triaged to a “Fast Track” area, while those with higher acuity, e.g., with abnormal vital signs at Triage, or those with potentially high severity presenting complaints are directed immediately to an acute care bed. Only in truly exceptional cases would the Triage process itself result in the transfer of a minor problem to some lesser venue of care without the benefit of the full screening and stabilization evaluation mandated under EMTALA.

3. If Emergency Care is not needed, do you know if a lesser code is used to bill the visit?

All patients evaluated in an Emergency Department are subject to CPT codes appropriate for Place of Service (POS) 23. The range of CPT Evaluation and Management (E/M) codes extends from 99281 through 99285, and to Critical Care Services (99291-92), and Observation Services, in function of the intensity of the E/M service provided. Compliant coding requires that the patient record contain sufficient clinical information to sustain the particular level of service coded. “Lesser codes” would correspond to 99281 and 99282 coding which constitute less than 5 percent of all ED visits on average, however these codes make no determination and contain no implication relating to the phrasing “if Emergency Care is not needed”.

4. Do you think any of the following issues contribute to the patient rationale for/play a role in ED visits?

• Access to PCP and urgent care centers
• Patient perception in severity of illness
• Ethnicity/cultural issues

A number of these questions have been addressed in the Introduction and in previous answers.

In an important study (National Study of Barriers to Timely Primary Care and Emergency Department Utilization Among Medicaid Beneficiaries, Cheung PT, et al; Annals of Emergency Medicine: Vol. 60, No.1, 4-10, March 2012) the authors identified the increasing prevalence of barriers to timely primary care and their contribution to increasing ED utilization. In an analysis of 230,258 adult patients who participated in the 1999 to 2009 National Health Interview Survey, frequently identified barriers included: “Couldn’t get through on telephone” (4.0 percent), “Couldn’t get an appointment soon enough” (7.2 percent), “Waiting too long in physician’s office” (7.6 percent), “Not open when you could go” (3.8 percent), “No transportation” (7.6 percent). Identified barriers to care were consistently and more frequently found among Medicaid beneficiaries than among non-Medicaid patients.

The issue of “no transportation” may apply specifically to some urgent care centers more remotely located in comparison to urban ED’s which are often sited on public transportation lines.