Knowledge Base Article

In the August 20, 2019 Wednesday@One, we published an article about Appropriate Use Criteria (AUC) which will enter the Educational and Operations Testing Period beginning January 1, 2020. During this phase, providers are encouraged to participate, but claims will not be denied for lack of AUC claim elements. In that article, I stated, “It is confusing to me why applicable settings include hospital emergency departments when patients with an emergency medical condition are exempt.” I reached out to CMS for further clarification and they directed me to the CY 2019 Physician Fee Schedule final rule on page 59699 (https://www.govinfo.gov/content/pkg/FR-2018-11-23/pdf/2018-24170.pdf) for more information about this exception. I appreciated their prompt response and I think it actually did answer my question.

After reading the above reference and the section of the Social Security Act which it references, I determined that the difference in the exception versus all services provided in a hospital emergency department depends on differing definitions of the term “emergency.”

The exception for following the AUC guidelines does not apply to section 1867(a) of the Act which is where the requirement for an appropriate medical screening examination is set forth. This section states,

• “In the case of a hospital that has a hospital emergency department, if any individual (whether or not eligible for benefits under this title) comes to the emergency department and a request is made on the individual’s behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (within the meaning of subsection (e)(1)) exists.”

We all know that many patients present to the emergency department for conditions that are not really “emergencies” as defined further in the Act. Advanced imaging services provided for these types of conditions will be required to follow the AUC guidelines.

It is only those “serious jeopardy” emergency conditions as defined in section 1867(e)(1) of the SSA that are exempt from the AUC requirements. This section of the Act defines “emergency medical condition” to mean

• a medical 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 health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
• serious impairment to bodily functions, or
• serious dysfunction of any bodily organ or part; or
• with respect to a pregnant woman who is having contractions—
• that there is inadequate time to effect a safe transfer to another hospital before delivery, or
• that transfer may pose a threat to the health or safety of the woman or the unborn child.

The discussion in the 2019 MPFS Final Rule does clarify that the exception to using AUC includes “instances where an emergency medical condition is suspected, but not yet confirmed. This may include, for example, instances of severe pain or severe allergic reactions. In these instances, the exception is applicable even if it is determined later that the patient did not in fact have an emergency medical condition.”

Even though I think I understand the distinction between less severe conditions of ED patients and those with conditions placing the patient’s health in serious jeopardy, impairment or dysfunction, I am curious to see how CMS will make this determination for payment purposes once consultation and reporting of use of AUC is required. For example, an ED claim with a diagnosis of GERD could have been a patient presenting with chest pain, a condition that could potentially place the patient’s health in serious jeopardy. Is CMS going to perform a complex review to determine if AUC is required or not? If so, what documentation would they expect to see in the ED record to support that an emergency medical condition was suspected? I guess we will just have to wait and see how it all plays out.