emergency room visit high mdm

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ED Charting and Coding: Medical Decision Making (MDM)

Editor’s note (jan 13, 2023): .

The new AMA CPT 2023 Documentation Guidelines have been published and the coding elements within the medical decision making section have been revamped. See the ACEP FAQ page on the 2023 Emergency Department Evaluation and Management (E/M) Guidelines .

In this ED Charting and Coding Series, we have covered Introduction to ED Charting and Coding (PV Card); the History of Present Illness & Past Medical, Family, Social History; the Review of Systems; and the Physical Exam. At last we arrive at the crux of the chart: Medical Decision Making (MDM). In this final section, you show your work and your thought process.

CMS Assessment of Medical Decision Making

The Centers for Medicare & Medicaid Services (CMS) evaluates MDM based upon the highest 2 of the following 3 elements:

• The number of diagnostic and management options to be considered
• The complexity of data analyzed, including charts, tests, and other sources (family, EMS)
• The risk of complications, morbidity, and mortality associated with the presenting problem(s) and subsequently with the procedures and management options for them.

These elements are presented qualitatively in the following table. See each section below for more quantitative scoring systems.

Let’s work through a sample case, and discuss how each section is documented and then scored.

Diagnostic and Management Options

Begin your MDM section with a summary statement of the patient encounter and list your differential diagnosis:

Scoring the number of diagnostic and treatment options is accomplished in most places using the “ Marshfield Clinic Scoring Tool ,” which is not officially part of the E/M guidelines nor endorsed by CMS or the AMA. The tool tries to infer complexity from the nature of the problem and the effort it will take to address it. The following tables show the tool and the most common conversion from Marshfield “problem points” to the E/M guidelines element for number of diagnostic and management options.

The tool was developed for clinic appointments, but the American College of Emergency Physicians (ACEP) has recommendations to adapt it to the emergency department (ED) setting. The first distinction is new vs established problems. In the ED, most patients present with problems that are new to the examiner, so unless you are caring for a patient on a planned return visit, your cases will either be minor, self-limited problems (1 point for each problem) or new medical problems that require consideration, guidance for care, and often some kind of workup (3 or 4 points for each problem). Contrasted to the clinic setting, where testing is typically done between visits, in the ED we order, perform, and interpret most of our tests during the visit. So any new problem you can diagnose and manage by history and physical exam alone will score 3 points, and those requiring testing to guide diagnosis and management will score 4 points, as in the case of Ms. Example.

Data Review

The body of your MDM will describe how you work through your differential. Decisions based upon your history and exam require minimal additional information, but cases that require chart review, tests, and images are credited for increasing complexity.

To score your data review, you may use a table to calculate “data points” for the different kinds of testing, interpretation, and record review. In the table below, note that different kinds of testing score separately, and if you are providing your own read (even if you have a radiologist, cardiologist, or pathologist also on record) you get credit for that work. It’s important to include your interpretation of test results, both as part of your thought process and because your input counts.

As a side note, ECG interpretation must include ≥3 of 6 elements:

• Rate/rhythm
• ST-segment changes
• Comparison to prior
• Summary of the patient’s clinical condition

You may also interpret the telemetry monitor recordings, which should include a mention of rate and rhythm.

We can also address the level of risk involved for the presenting problem, testing, and treatment plan. The following table gives examples for risk, based upon the categories of presenting problems, testing required, and treatment plans. Important to note: the highest single item in any category determines the level of risk ( CMS Evaluation and Management Services Guide, PDF ).

The differential diagnosis for RLQ pain in a 25-year-old woman includes causes at each level of risk, and you should tailor both your differential and your workup appropriately to the presenting problem. Failure to account for higher-risk diagnoses, perform adequate testing, and appropriately escalate care are major areas of potential liability for EM providers. For Ms. Example, if you limited your workup to cystitis and ovarian cysts, this would be minimal to low risk . Considering pelvic inflammatory disease (PID) or other serious infection is  moderate risk . Being appropriately concerned for appendicitis, peritonitis, and ovarian torsion reaches high risk . Non-invasive testing (labs and radiology) is considered low risk , but use of IV opioids to treat pain places the management level at high risk (drug therapy requiring monitoring).

Our sample case demonstrates High Complexity MDM based upon extensive diagnostic and management options , extensive data review and analysis , and high risk . It was quite thoroughly documented, but the scoring could be accounted for with just two items: a new problem requiring testing and pain treated with IV narcotics.

Work Smarter, Not Harder: Show Your Effort

The MDM is arguably the most important section of the patient’s record. There are many styles of documentation depending on your system, our example reflects the style we have adopted since using computer dictation, and many will be much shorter. Regardless, every MDM should include 3 core elements:

• Explain the complexity of the diagnostic and management options available to you by giving a brief summary of your patient’s presentation followed by your differential diagnosis, no matter how short.
• Describe and interpret the data that you obtained and reviewed. Be sure to use a phrase such as, “on my interpretation,” when you independently interpret radiographs or ECGs and briefly summarize prior visits that you reviewed.
• Be sure to mention the risk the patient is at due to their underlying pathology, the testing that is required to make a diagnosis, and the treatments that you administer or prescribe.

This example demonstrates the core elements of the MDM up to the point of admission for billing purposes, but leaves out the greater proportion of charts you will write: discharges. Documentation of discharge planning, return precautions, and unplanned discharges including those leaving against medical advice (AMA) and risk-minimizing measures will be covered in a future post.

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Bjorn Watsjold, MD

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• ED Charting and Coding: Medical Decision Making (MDM) - November 16, 2016
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Kenneth Dodd, MD

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Medical Decision Making

View full MDM levels/elements grid

Levels of MDM

The original four levels of MDM (straightforward, low, moderate, and high) have not changed for 2021. However, as codes 99201 and 99202 previously both described "straightforward" MDM and were differentiated only by history and/or exam elements, code 99201 will be deleted and E/M services previously reported using 99201 will be reported using 99202 beginning in 2021.

The table below shows the level of MDM for each office/outpatient E/M code.

MDM Element Titles

Each level of MDM continues to have the same three elements. For 2021, the titles of these three MDM elements have been revised to better reflect the medical decision making process. The table below highlights the revisions to the MDM elements titles effective January 1, 2021, for office/outpatient E/M codes.

The level of MDM for office/outpatient E/Ms continues to be based on 2 out of 3 elements.

Element 1: Problems Addressed

• The number and complexity of problem(s) addressed.

CPT defines a problem as "…a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter."

Element 2: Data Reviewed and Analyzed

• The amount and/or complexity of data to be reviewed and analyzed.

This element recognizes each unique test, order, or document to meet the requirements for each level of MDM. Tests can include imaging, laboratory, psychometric, or physiologic data. The difference between single or multiple unique tests is based on the applicable CPT code(s) for such tests. For example, CPT code 80047 describes a clinical laboratory panel that includes and requires multiple tests but is considered a single test because only one CPT code is reported.

Important for surgeons: Independent interpretation of a test performed by another physician and not separately reported by the surgeon (e.g., independent interpretation of a chest x-ray) meets a criterion for this element as "data analyzed." In addition, discussion of patient management (e.g., surgeon and physical therapist) or test interpretation with external physicians (e.g., surgeon and pathologist) meets a criterion for this element. However, external physicians cannot be in the same group practice or same specialty/subspecialty as the billing surgeon. For example, reviewing an image with your office partner would not count as a criterion for this element.

Element 3: Risk

• The risk of complications and/or morbidity or mortality of patient management.

CPT has developed an extensive definition for risk:

"The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as ‘high,’ ‘medium,’ ‘low,’ or ‘minimal’ risk and do not require quantification for these definitions, (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of medical decision making, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes medical decision making related to the need to initiate or forego further testing, treatment and/or hospitalization."

The MDM table provides examples of risk for moderate and high MDM that many surgeons can relate to, such as a decision regarding minor surgery with identified patient or procedure risk factors or a decision regarding elective major surgery without identified patient or procedure risk factors.

Download the Office E/M Coding Changes Guide (PDF)

Documentation of ED Encounters

Author credentials.

By the end of this module, the student will be able to:

Understand the utility of written documentation as it relates to the practice of emergency medicine.

Be able to document an emergency department (ED) patient encounter using the SOAP note organization/format.

Recognize the importance of describing medical decision making in the assessment and plan section of ED documentation.

Introduction to Medical Documentation

Why do I have to write EVERYTHING down? Why can’t I just take care of my patients? All this documenting is preventing me from doing my job!

These statements reflect the frustration that many physicians feel regarding how much time completing written medical documentation can take. Balancing the time demands of patient care and charting can be difficult. In this chapter, we explain the purpose and structure of the ED note in order to help you build the skills needed to effectively document your patient encounters and medical decision making in the ED medical record. 

Purposes of the Emergency Department Note

Why is written documentation so important? The ED note serves multiple purposes:

• Communication – Rarely is an ED encounter so self-limited that no one else needs to know about it. Our chart is the main way we communicate with other health care clinicians (and even with patients) about what happened in the ED (e.g., diagnostics, treatments, our thought processes, discussions with patients and families about their concerns and desires, discussions with consultants about their recommendations and patient care plans).
• Billing – Medical documentation serves as the primary tool for coding and billing for patient care services provided in the ED.  
• Medicolegal Protection – The medical record is a log of the events and thought processes that occurred during the ED visit. In the event of a poor clinical outcome, patient complaint, or lawsuit, the chart is the final (often the only) representation of what happened during the patient encounter. The adage of “if it wasn’t written down, it didn’t happen” has haunted many a competent and well-meaning physician. The ED record must be able to serve as our defense in these situations.
• Quality Improvement Reviews – Chart review is one of the main ways that health systems use to improve future patient care. Details that may not seem important to you (or your patient or consultant) might be very important to reviewers interested in quality or process improvement.
• Research – Retrospective chart reviews are often the starting point when asking a clinical research question. Clear documentation helps investigators gather data to devise future studies to improve patient care.
• Utilization Management/Risk Management – The hospital administrators review medical records to establish timelines and points of delay. Your charting (e.g., time documentation) can give them the tools they need to fix these delays.

Differences between ED notes and clinic or inpatient notes

Charting is important for all medical encounters. That being said, there are some specific differences between ED notes and notes by other clinicians.

Time Pressure s-  Clinicians in the ED are often under tighter time constraints than those in other care areas, resulting in limited time for documentation and placing a premium on efficient charting (a compromise between brevity and thoroughness: including everything you need to know, but nothing that you don’t). The hectic environment in the ED makes it difficult to remember exactly what happened and when, so timely completion of charting is critical for accuracy.  Ideally, documentation should be complete at the time of final disposition.

A Note Must Stand Alone - Each ED note is an independent document as opposed to the chapter-like inpatient progress note or clinic note. In ED documentation, we reflect on information gathered from the patient encounter and diagnostics, how we dealt with the emergent issue at hand, any changes in clinical status, and plans for future care (such as hospital admission or outpatient follow up).   

• Billing Mechanics - ED visits are billed differently than most other encounters. Our charts are graded on a complexity level from 1-5 based on the description of our medical decision making (e.g., complexity of problems addressed and of data review). If our medical decision making isn’t clearly documented, the chart gets significantly down-coded.  Emergency physicians (EPs) can also bill for procedures they perform, and these must be recorded appropriately.

Different Goals of EPs vs Admitting or Clinic Clinicians - As opposed to comprehensive care, the ED role is assessment, stabilization, and appropriate disposition. We must have a “worst-first” approach to the differential diagnosis (DDx), rather than always identifying a single, definitive diagnosis. Charting needs to reflect which problems are being addressed during the ED encounter as well as our clinical reasoning regarding each one.  Explaining your thought processes about the patient’s care is one of the most important goals of ED notes. 

Medical Scribes - Because of the time pressures involved in evaluating and treating patients and keeping up with documentation, medical scribes are becoming increasingly common in EDs.  Scribes must also understand the differences between documentation in the ED versus  other parts of the health system. Scribe charting must be reviewed carefully since you are ultimately responsible for what scribes document.

Keep these purposes and differences in mind (Figure 1) as you complete your charting. Put yourself in the shoes of the people who will read your note. Remember things that frustrate you when you read other clinicians’ documentation and learn from their mistakes. Focused practice is needed in order to improve the clarity and efficiency of your documentation.  

Qualities of an Emergency Department Note

The ED note should paint a picture of the patient encounter: how it began, how and why it evolved, how it came to a conclusion, and where it needed to go from there. It should tell a story that the reader can easily follow. Qualities that are essential to maintaining high quality medical records include completeness and accuracy in addition to conciseness and organization.

Completeness and Accuracy-  A medical note must convey the pertinent details of the patient encounter and subsequent plan of care without including superfluous information. The paradox is that we often don’t know what will turn out to be important until later in the patient’s ED stay. For less experienced students, all information can seem potentially relevant to a patient’s presenting complaint(s) (and in fact it may turn out to be so!). Be patient with yourself -with more and more clinical experience, you will quickly gain a better understanding of what is most relevant or pertinent to include in your written documentation.

• Conciseness and Organization – As you start out in the ED, focus first on being accurate and complete, then strive to be concise. By effectively organizing your note, you will achieve conciseness by avoiding duplication and be able to meet the expectations of other health professionals reading your notes. In EM, the emphasis is on capturing the relevant details of the patient’s presentation that drive your DDx as well as describing your medical decision making. The question “Does this patient have a serious, life or limb-threatening condition?” is always on the mind of the EP, and your answer must be reflected in your medical documentation. Both the type of information that you select to include in your note and how you choose to organize it help accomplish this task.

Structure of the Emergency Department Note 

The ED note incorporates components of a comprehensive H&P, a focused SOAP note, and a discharge summary. The challenge is including sufficient information to support your DDx, diagnostic/treatment plans, and conclusions while still keeping the note concise and quickly readable. Since most patients in the ED are initially unfamiliar with undifferentiated complaints, you must gather a fairly comprehensive H&P before building an appropriate DDx and treatment plan. Although EPs are interested in why the patient is in the ED today, peripheral information may be very relevant. Not everything you learn from the patient will go into your note. Everything that gets included in your note should be PERTINENT: focus on the patient’s presenting complaint(s) and the problem(s) that needed to be addressed.

ED notes generally follow a templated structure, which dictates much of the formatting and organization of your documentation. The first section is your summation of the patient’s history. Auto-populated portions (e.g., meds, family history, past medical history(PMHx)) can be helpful, but be careful because you are ultimately responsible for the accuracy of these sections. “Checkbox” sections (e.g., review of systems (ROS), physical exam) speed documentation, but be sure to only document what you actually asked about/parts of the exam that you actually performed. Avoid the temptation to click every box and remember to double check that you clicked the appropriate boxes (e.g., to avoid accidentally marking the “normal” box when there were actually abnormal findings). There is a section to capture the “ED course” and your “medical decision making.” These areas are used to chronicle how your patient responds to any treatments, if their clinical status changes, what your initial clinical impression is, how subsequent results influence your initial impression, and your plan for final disposition. If the patient stays in the ED past the end of your shift, sign-out notes may need to reflect the transitions of care between ED clinicians.

In some notes, the assessment/plan appears before the subjective and objective portions of the note (an “APSO” note). This reordering highlights the importance of what you think is going on with the patient (i.e. your interpreting skills) and what you plan to do about it (i.e. your management skills) rather than your reporting skills of the history and exam findings and results of diagnostics. 

The Subjective Section of the Emergency Department Note

The subjective section contains two essential elements: the chief complaint and a history of present illness. Classically, the chief complaint (CC) is the main reason (often a symptom such as pain) that the patient is seeking medical care and is often captured in the patient’s own words (e.g., “I’m here to find out the cause of my knee pain.” “I need of a refill of medications.” “My wife thinks this chest pain needs to be checked out.”). The history of present illness (HPI) accurately and completely captures the details of the chief complaint. The HPI should be a chronological story that identifies the cardinal attributes of a symptom/problem: onset, location, quality, severity, timing/frequency, alleviating factors, and aggravating factors. Acronyms such as OPQRST (Figure 2) or OLD CARTS, help make sure you catch all the key points. Often this distills down to 3-4 carefully crafted sentences.

Example: Patient says his wife is worried he “has got appendicitis.” Pain began 2 days ago with mild vague intensity and nausea (no vomiting) and didn’t get better with his usual Maalox. This morning the pain moved to RLQ and was so bad that he couldn’t roll over in bed, and EMS was called. 

The subjective narrative may also include ROS, PMHx, and other information you deem pertinent to addressing the presenting complaint. 

Example: CC = Chest pain

62yo obese diabetic man presents with chest pain reminiscent of his previous heart attack

Previously healthy 32yo competitive tennis player presents with sharp chest pain when reaching up for a serve, but no other associated symptoms

Documentation of current medications (prescribed and over the counter) and any medication allergies is essential to appropriate medical documentation in the ED as well as safe patient care.  The social context in which a patient seeks care can also affect their care plan and final disposition.

Example: CC = abdominal pain

45yo homeless alcoholic with gout presents for abdominal pain. He is out of all prescribed meds and has been using Advil to control his gout pain. [Advil increases risk of ulcers, GI bleeds and perforation. Homelessness and alcoholism affect patient’s ability to follow-up.]

When considering patients with chronic problems or an acute exacerbation of a chronic illness, there are some subtleties that you should consider. Quickly revisit the history of the chronic medical problem and confirm your understanding of the patient’s prior experiences with the disease. Report compliance with any medications or medication side effects, any current symptoms or complications related to the chronic illness, any end organ effects from the chronic illness, and any health maintenance needs related to the chronic illness. Finally, any specific information related to the patient’s reason for seeking medical care today or factors that impact the patient’s ability to interact with the health care system and follow through with care plans should be included in the subjective portion of the ED note.

Example: 

55yo man with well-controlled COPD presents for worsening wheezing exacerbation. Says he’s never been intubated and rarely hospitalized, but is visiting family from out of town and lost all of his meds and nebulizer in “lost-luggage-debacle.” 

[You may need to refill all medications for the duration of his trip, and you know he won’t be able to follow up readily until he returns home]

The Objective Section of the Emergency Department Note

The objective section is dedicated to what we can observe or measure during our interaction with the patient. Write this section using standard medical language (or commonly accepted abbreviations) and don’t include any quotes from the patient to describe the physical examination. Always include vital signs, general appearance, the relevant physical examination, and any laboratory or imaging results. Maintaining this order is important because your readers expect the information to be delivered in this way, increasing the efficacy of information transfer.

For both medical and legal reasons, you should provide details of exactly (and only) what you examined during the encounter. Avoid general terms like “normal” (which implies a completely normal exam) or “WNL” (you may mean “within normal limits” but lawyers can turn it into “we never looked”). Specifically state what you checked, saw, heard, palpated in order to incorporate this information into the patient’s medical record. If you are able to do so, including pictures in your charting is very helpful for documentation of skin lesions, soft tissue injuries, etc. Many EPs have a core set of exam maneuvers that they automatically perform on every patient even if it does not relate directly to the patient’s presenting complaint.

Appears awake, alert, conversant and not in acute distress.

Pulm: unlabored equal breathing without wheezes or rales

CV: Clear S1S2 without murmurs. Equal brisk pulses and cap refill, no edema.

Abd: Soft with normal bowels sounds. No tenderness, guarding, masses or bruits appreciated.

This highlights the need to perform a fairly complete physical exam on all patients in order to put abnormal physical examination findings into context. “If you didn’t document it, then you didn’t do it” certainly applies, but so does “if you document it, you better have done it.” Create a complete and accurate note by being thorough and conscientious with your exam documentation. If you order labs, EKGs, or radiologic studies, include the results/interpretations at the end of the objective portion or in the ED course once they are available. Note whether interpretations are your independent reads, preliminary radiology interpretations, or final radiology reports.

The Assessment/Plan Section of the Emergency Department Note

This section is arguably the most important part as it displays your clinical reasoning about the case. Here you move from recorder/reporter to manager, and the real “doctoring” begins. Medical decision making (MDM) means discussing what you think may be going on with the patient, why you think it, and what you’re doing about it. Sometimes this is very straightforward (e.g., simple, superficial laceration), but it can be very complex in other cases (e.g., suspected pulmonary embolism in a patient with a recent head bleed). To keep the assessment portion of your ED note concise and organized, it is helpful to break the assessment section into its component parts: the summary statement, the problem list, and the discussion of the DDx.

The summary statement is 1-2 sentences that capture the reason the patient came to the ED and highlights important elements from the subjective and objective portions of the note. It is NOT just a repetition of the chief complaint and the patient identifiers. Rather it is a concise summary that puts the chief complaint into context while also risk stratifying the patient (Figure 3). This statement is often where the reader looks first because it should both sum up what you have done so far and hint at where you’re going in the future . Often, the process of writing up your summary statement, problem list, and DDx helps to clarify your thinking about the patient and organize your thoughts about their clinical presentation. Stop and put some thought into this statement.

The problem list is just that. For some patients, this list may include only 1 item, but it is not uncommon for an ED note to have several different problems listed. Often secondary problems have a direct impact on the initial one (e.g., hypertension and coagulopathy in a patient with an aortic dissection). Each active problem needs to be listed and discussed in the assessment and plan. Often the first problem listed is the chief complaint (or its direct cause). Other problems, if immediately relevant, are listed next on the problem list. Finally, any stable or chronic medical problems that may be relevant to the patient’s presentation and that are addressed during this visit are listed. 

Each acute problem in your problem list needs a DDx, an explanation, and/or an indication of its relevance. Utilizing a prioritized DDx (Figure 4) reflects how EPs prioritize the worst and most likely conditions in their differential.  You should include a brief discussion of the conditions that you are considering as part of the DDx along with reasons why you think these conditions should be considered or ruled out as part of the medical encounter. This section is typically wrapped up with a “Plan.” which often straddles the prioritized differential and the disposition section (see below).

Problem List

• Aortic dissection: most likely DDx based on character of pain and new wide mediastinum.  CT pending. Controlling blood pressure, heart rate, and pain.
•  Consider pulmonary embolism, acute coronary syndrome, other causes (tests pending, aspirin held till CT)
• Will admit ICU (surgical if dissection, medical if CT neg)

Coagulopathy

• Reverse with FFP/PCC

Atrial fibrillation

• Rate controlled on esmolol
• Discussed with cards regarding anticoagulation reversal

Hypertension

• Hypertensive emergency- dissection vs ACS vs other
• Controlled now on esmolol
• Will need good oral control
• Currently stable

Chronic low back pain

• Avoid NSAIDs (antiplatelet risk)

 Disposition for the Emergency Department Note

Ultimately you will need to decide on the final disposition for your patient. Your assessment and plan section should allude to their ultimate disposition. The second most important question in emergency medicine (behind “sick or not sick?”) is “Is this patient being admitted or discharged?” If you are admitting, you should detail the level of care recommended (such as the ICU, step-down unit, telemetry unit, regular floor, or brief observation unit) depending upon the patient’s condition, severity of illness, and/or vital signs. If you are discharging the patient, you should always address follow-up plans with a primary care physician, a specialist, or back in the ED. This closes the loop, allowing assessment of the appropriateness and effectiveness of your diagnosis and treatments. 

Although not always integrated into the ED note, return precautions are a vital part of the medical record. The importance of return precautions (outlining specific reasons why a patient should come back to the ED) cannot be overemphasized. Return precautions must include details on specific symptoms, timing, severity, and any other characteristics that should prompt re-evaluation in the ED (Figure 5). It is best to err on the side of caution with these precautions. Discuss them with the patient. Document that they are understood and agreed upon and that the patient has the insight and support to return to the ED if needed. While not explicitly part of your ED note, the discharge paperwork and return precautions are definitely part of the patient’s medical record. As such, you are responsible for making sure these are done correctly.

Final Thoughts about the Emergency Department Note

Medical documentation is an integral part of the practice of emergency medicine.  Understanding the purposes and uses of the ED note will help to shape the way in which your notes are written and organized.  While ED documentation follows a common structure, EPs can tailor their notes based on personal preferences and the expectations of the specific ED is which they work.  Certainly the ED note must detail the pertinent information gathered from the patient and provide a record of the patient’s care during their stay in the ED; however, the most important purpose of the ED note is to capture the emergency physician’s medical decision making.

Pearls and Pitfalls

The ED note serves multiple purposes: communication, billing, medicolegal protection, quality improvement reviews, research, and utilization management/risk management.

The emphasis is on capturing the relevant details of the patient’s presentation that drive your DDx as well as describing your medical decision making.

Auto-populated portions and “checkbox” sections of the chart can speed documentation, but be sure to only document what you actually asked about/parts of the exam that you actually performed. Avoid the temptation to click every box and remember to double check that you clicked the appropriate boxes.

The assessment/plan section is arguably the most important part as it displays your clinical reasoning about the case (what you think may be going on with the patient, why you think it, and what you’re doing about it). 

For discharged patients, return precautions are vitally important and must include details on specific symptoms, timing, severity, and any other characteristics that should prompt re-evaluation in the ED.

https://canadiem.org/a-guide-to-charting-in-the-ed/  

https://www.acep.org/patient-care/policy-statements/patient-medical-records-in-the-emergency-department/  

https://www.emra.org/be-involved/committees/education-committee/medical-student-documentation/  

2023 Documentation Guideline Changes for ED E/M Codes 99281-99285

On July 1, 2022, the American Medical Association (AMA) released a preview of the 2023 CPT Documentation Guidelines for Evaluation and Management (E/M) services. These changes reflect a once-in-a-generation restructuring of the guidelines for choosing a level of emergency department (ED) E/M visit impacting roughly 85 percent of the relative value units (RVUs) for typical members. Since 1992, a visit level was based on a combination of history, physical exam, and medical decision-making elements. Beginning in 2023, the emergency department E/M services will be based only on medical decision making.

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• Avoid Patient History Documentation Errors in Medical Coding

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The American College of Emergency Physicians (ACEP) represents the specialty in the AMA current procedural technology (CPT) and AMA/Specialty Society RVS Update Committee (RUC) processes. In fact, they are your only voice in those arenas. The AMA convened a joint CPT/RUC work group to refine the guidelines based on accepted guiding principles. Although the full CPT code set for 2023 has not yet been released, the AMA recognized that specialties needed to have access to the documentation guidelines changes early to educate both their physicians on what to document and their coders on how to extract the elements needed to determine the appropriate level of care based on chart documentation. Additionally, any electronic medical record or documentation template changes will need to be in place prior to January 1, 2023, to maintain efficient cash flows and ensure appropriate code assignment.

ACEP was able to convince the Joint CPT/RUC Workgroup that time should not be a descriptive element for choosing ED levels of service because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time. It would be nearly impossible to track accurate times spent on every patient under concurrent active management.

The prior requirements to document a complete history and physical examination will no longer be deciding factors in code selection in 2023, but instead the 2023 Guidelines simply require a medically appropriate history and physical exam. That leaves medical decision making as the sole factor for code selection going forward. These changes are illustrated by the 2023 ED E/M code descriptors, which will appear as follows:

The 2023 E/M definitions have been updated to reflect simply Medical Decision Making determining the level.

• 99281: ED visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional.
• 99282: ED visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
• 99283: ED visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low medical decision making.
• 99284: ED visit for the evaluation and management of a patient which requires a medically appropriate history and/or examination and moderate medical decision making.
• 99285: ED visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high medical decision making.

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WEATHER ALERT

13 warnings in effect for 14 counties in the area

‘i would send my momma here,’ new 24/7 emergency room clinic, top care er, opens in houston heights.

Ahmed Humble , Digital Content Producer

HOUSTON – Imagine needing to go to the doctor’s but being too afraid to because you don’t have insurance. This is the reality for many folks, even myself for many years.

Fortunately, there are dedicated healthcare professionals like Dr. A. Kudrath (otherwise known as Dr. A.K.) who are well aware of patient struggles. He reminded folks that during Thursday’s ribbon-cutting ceremony for his newest Emergency Room clinic, Top Care ER , which opened up in the Heights on N Shepherd.

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Voicing his concern to keep patients healthy without having to worry about whether their insurance will cover treatments, especially life/death treatments, Dr. A.K., said the clinic will cover their costs. Dr. A.K. said part of this is because the focus should be delivering quality care to patients, without them having to worry about things like “surprise costs.”

“We never send surprise bills,” he said. “If your insurance leaves you hanging, we negotiate on your behalf so you don’t get stuck with any bills.”

Part of this, Dr. A.K. said, was to ensure patients can focus on their health.

“I think it’s important to say because I want to alleviate the concern that people might have,” he continued. “So you take that out of the equation, and what’s left? Quality staff and care.”

RELATED: ‘It’s absolutely outrageous’: Houston resident charged surprise $400 ‘facility fee’ after doctor visit

Off camera, he mentioned to KPRC 2 Digital Producer Ahmed Humble someone may choose to ignore something like a pain in their left arm, because they feel like that’s their only symptom but could be having a heart attack, and not taking it seriously could cause permanent damage to their health.

Top Care’s website’s billing page also claims, “If you do not have insurance, are underinsured, or if paying the full amount for treatment would cause financial significant difficulties, please contact us for financial assistance options, which may reduce the out-of-pocket costs for your visit.”

“Our vision is that this is the place that we would send our own families to,” Dr. A.K. said. “I would send my momma here and hope all of you guys would send your momma’s here and all your family members. Anytime you need something, reach out. We’re happy to be in the Heights.”

SEE ALSO: Free medical care coming to all Houston ISD campuses next school year | Medicare and Social Security go-broke dates are pushed back in a ‘measure of good news’

This is not the first time Dr. A.K. has been involved in the community, however. He has been behind several freestanding emergency rooms across the Greater Houston area, along with his partner, Cruize Gaj, a Health & Wellness Marketing Consultant and partner for Top Care ER - Houston Heights.

“We are conveniently located in the heart of the Heights area and want to serve our community for all their medical needs,” he tells KPRC 2 Digital Content Producer Ahmed Humble. “We have also been assisting with patients who have suffered motor vehicle accidents and any work injuries. Our goal is to keep the community safe.”

The event was organized with the help of the Greater Heights Area Chamber of Commerce.

“We are so excited that Top Care is here in our chamber because they are a great asset and Dr. A.K. is amazing!” Rachel Goldstein, Communications Director for Greater Heights Area Chamber of Commerce said.

To learn more about Top Care ER, visit their website.

Copyright 2024 by KPRC Click2Houston - All rights reserved.

About the Author

Ahmed humble.

Historian, educator, writer, expert on "The Simpsons," amateur photographer, essayist, film & tv reviewer and race/religious identity scholar. Joined KPRC 2 in Spring 2024 but has been featured in various online newspapers and in the Journal of South Texas' Fall 2019 issue.

Knowing the rules will give you the confidence to submit this seldom-used code.

CHRISTIAN HERMANSEN, MD, AND JOAN JACKSON, CPC, CPC-H, LPN

Fam Pract Manag. 2014;21(6):12-16

Author disclosures: no relevant financial affiliations disclosed.

The CPT evaluation and management (E/M) code 99215, “Office or other outpatient visit for an established patient,” is rarely used, accounting for about 5 percent of E/M visits. 1 However, depending on the fee schedule, payment for 99215 could be about 25 percent more than for 99214, so when the clinical circumstances and your documentation support 99215, you should claim the payment that you've earned. Of course, inappropriate or excessive use of 99215 can result in audits. Understanding the requirements as well as the differences between 99215 and 99214 – and between 99215 and the newer transitional care management code 99496 – will help to ensure that you can code with confidence.

99215 AND TRANSITIONAL CARE MANAGEMENT

Both 99215 and the transitional care management code 99496 require high complexity medical decision-making. The 99496 code requires that the office contact the patient within two days of discharge and provide an office visit within seven days of discharge with high complexity medical decision-making. Practices that fall short of meeting these and the other detailed requirements associated with code 99496 could bill 99215 instead, assuming documentation and medical necessity support the level of service. Code 99215 pays approximately $80 less per visit. The 2014 work RVUs (relative value units) are 2.11 for 99215 and 3.05 for 99496. For more information, see “ Transitional Care Management Services: New Codes, New Requirements ,” FPM , May/June 2013.

The history component of a 99215 visit requires a comprehensive level of documentation. Documenting a comprehensive history means addressing four elements of the history of the present illness or the status of three chronic diseases in your documentation. Ten of the 14 body systems should be reviewed and commented on – significantly more than the two required for documenting a level-four history. At least two aspects of past, family, and social history should also be included.

This article focuses on the 1997 version of the E/M guidelines, which lists 14 organ systems and body areas comprising the general multisystem exam. Each has multiple elements. For instance, four exam elements define the “Respiratory” portion of the general multisystem exam: assessment of respiratory effort, percussion of the chest, palpation of the chest, and auscultation of the lungs. Coding 99215 requires a comprehensive exam in which two elements in each of nine or more organ systems and body areas are documented. A common way of remembering the exam documentation requirements for each level of exam is to build from a problem-focused visit to a comprehensive visit using the “rule of sixes.” (See “ Rule of sixes for general multisystem physical exam documentation .”)

The 1997 guidelines are quite specific and rely on documentation of individual bullets, which makes it easier to support the level of service submitted. (For more information, read “ Exam Documentation: Charting Within the Guidelines ,” FPM , May/June 2010.) The 1995 guidelines are vague by comparison and may create trouble if your definition of the exam does not coincide with the definitions used by the auditor, so we recommend using the more specific 1997 guidelines.

Medical decision-making

Medical decision-making should be the primary driver for code selection. For example, a physician may treat a patient for a hangnail and perform a comprehensive history and physical examination in the process, detailing every inch of the patient's history and performing an exam of his or her entire body. However, if the patient does not require medications, testing, or even a bandage for the hangnail, it is doubtful that the high level of care provided was medically necessary. We urge you to routinely make medical decision-making one of the two key components used for deciding if the patient's care is worthy of the 99215 code.

Medical decision-making is also the most complex of the three key components of the documentation guidelines, having three subsections: problem points, data points, and risk. These help determine the level of medical complexity from minimal complexity to high complexity. High complexity medical decision-making is associated with a 99215 visit. Two of the three subsections (problem, data, or risk) are needed for determining the level of medical decision-making. Typically, risk is used as one of the defining criteria; however, any two of the subsections could be used as the basis for code selection. (See “ The elements of medical decision-making .”)

Problem . Although a point system for quantifying the diagnoses and management options associated with patients' health problems is not an official part of the E/M documentation guidelines, many Medicare contractors use a point system for educational and auditing purposes. A total of four points is associated with high complexity medical decision-making. Points are assigned as follows:

Each minor problem earns one point with a maximum of two,

Each stable established problem earns one point with no maximum,

Each established but worsening or uncontrolled problem earns two points,

One new problem that does not need workup after the visit is worth three points and, if additional workup is needed, four points.

Data . A point system is also used for quantifying information gathered or requested during the visit. Again in this section of the guidelines, a total of four points meets the high complexity decision-making metric. Each of the following tasks earns one point regardless of the number of tests ordered:

Reviewing or ordering lab tests,

Reviewing or ordering radiology tests,

Reviewing or ordering medical studies such as pulmonary function tests or electrocardiograms.

The following tasks also earn points:

Documenting a discussion of contradictory or unexpected test results with the testing physician (one point),

Independently reviewing an image, specimen, or tracing (two points),

Reviewing old records and summarizing them in the record (two points),

Requesting old records or obtaining history from a source other than the patient, such as a family member or an emergency medical technician (one point).

Risk . This element takes into account the risk of complications, morbidity, and mortality based on the patient's condition. High risk is associated with high complexity medical decision-making. High risk could be associated with visits involving patients who have severe exacerbations of their problems or acute injuries that pose a threat to bodily functions. Diagnostic procedures or management options associated with highly complex care include cardiac electrophysiology studies, diagnostic endoscopy, discography, major surgery, parenteral controlled substances, or drug therapy with the need for intensive monitoring. For example, a high-risk visit might involve a patient who requires a parenteral medication in the office such as an injection for a migraine, supplementary fast-acting insulin for hyperosmolar hyperglycemia cases, or warfarin adjustment due to a supratherapeutic international normalized ratio. Documentation of the decision to de-escalate care in situations of poor prognosis is also a mark of a high-risk visit.

The assessment of risk of the presenting problem or problems is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk for selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment.

Time-based coding

Alternatively, if more than 50 percent of the face-to-face portion of the office visit was spent counseling and coordinating care, you can code it on the basis of time. Your documentation should reflect your discussion or coordination of any of the following:

Diagnostic results, impressions, or recommended diagnostic studies,

Risks and benefits of management (treatment) options,

Instructions for management (treatment) or follow-up,

Importance of compliance with chosen management (treatment) options,

Risk factor reduction,

Patient and family education.

If you and your patient spend more than 20 minutes of a 40-minute face-to-face visit together in this manner, a 99215 code is justifiable as long as you have detailed documentation of the context of the counseling and care coordination.

Note that new codes for complex care coordination (99487-99489) will take effect in January 2015. These may affect the frequency with which physicians use time-based coding, particularly for higher levels of service.

Don't overlook 99215

Family physicians may hesitate to code 99215. However, when conditions warrant a comprehensive history or physical exam and high complexity medical decision-making, 99215 can be the most correct and lucrative option.

To get a sense of whether your current use of 99215 is in line with benchmarks, analyze your E/M coding profile using the “ Coding frequency comparison spreadsheet ” which is available from the FPM Toolbox . We've also included “ Test your coding skills ” so that you can apply what you have learned to several clinical vignettes.

TEST YOUR CODING SKILLS

The patient is a 46-year-old male with diabetes who is back to see you after visiting the emergency department the day before for acute nausea and vomiting. The patient had chest pain and was tested for a possible blood clot with a CT scan that was negative for pulmonary embolism. The patient is no longer with chest pain but complains of fatigue and slight abdominal pain. He cannot tolerate crackers, lives with his wife, and drinks two beers every night at bedtime. No family history of heart disease and no allergies. Medications include simvastatin, lisinopril, metformin, and glyburide.

Vitals: BP 100/60 (last BP 146/86), P 56, WT 240, RR 20, Temp 99.2.

General: Appears older than stated age, dry heaving in office, obese, moderate distress.

HEENT: PERRL, slight conjunctival injection, mild pharyngeal edema, deviated septum on right.

Neck: No JVD, no thyromegaly.

Lymph: No cervical, axillary, or inguinal adenopathy.

Cor: Brady S1/S2, 1/6 systolic murmur.

Lungs: Decreased BS bilaterally without wheeze or crackles, normal effort, no dullness to percussion.

Abdomen: Diffuse mild abdominal pain without rebound or guarding, no organomegaly.

Extremities: No clubbing or cyanosis, 1+ edema bilaterally.

Skin: No rashes, tattoo on left scapula.

Neurological: CN 2-12 intact; normal DTRs bilaterally, symmetrically; muscle strength seems normal throughout.

A1C in office 10.2, last A1C 3 months ago 13.4.

Assessment/Plan:

Acute nausea/vomiting, recent chest pain, mild anemia.

Suspect lactic acidosis given CT scan and metformin.

Can be life threatening so will send to emergency department for potential hemofiltration and IV fluids.

See answer.

The patient is a 36-year-old female who has returned to the office with acute sharp stabbing RLQ pain with nausea/ vomiting since 2 p.m. The patient has no desire to eat and reports having a low-grade fever at home but no chills. Not better with ibuprofen. No chest pain/shortness of breath/rash/dysuria/myalgia/sore throat/numbness/vision changes. Smokes one pack per day. Previous history of GERD and PCOS. Current medication is metformin.

Vitals: BP 96/88, P 114, RR 20, Temp 101.6.

General: Sick appearing, in pain, obese.

Neck: No JVD, supple.

Cor: Brady S1/S2.

Lungs: CTA bilaterally.

Extremities: No edema.

UA in office: Positive for ketones but no blood or leukocyte esterase.

Urine pregnancy negative.

WBC in office 16.5.

Acute abdominal pain with rebound tenderness, leukocytosis.

Likely needs imaging to rule out appendectomy, other abdominal pathology.

Needs IVF, to consider evaluation for sepsis given hypotension.

Start hydromorphone 0.2 mg IV once while awaiting transport for ED/imaging.

Will contact hospitalist as FYI.

The patient is a 16-year-old male who returned for follow-up for depression and hypothyroidism. You have not examined him for about four months. The patient states he is not doing well. He continues to have significant problems with his mother since her divorce. He is getting terrible grades in school mostly because of the distraction of constant teasing. During continued nightmares, he recognizes a face he believes resembles his father. He has not felt comfortable talking about this until now, but states his father sexually abused him as a child. He thinks his dreams represent a flashback to those events. He has not seen his father since he moved away but gets sweaty just thinking about him. Medications include Paxil and Synthroid, but they have been missed due to a change in insurance plans.

General: NAD, some psychomotor agitation, and crying occasionally. We spent 45 minutes together with greater than 50 percent of the time spent counseling and coordinating care.

Depression; probable PTSD; hypothyroidism.

Prozac now covered by insurance; see medication flow sheet.

Discussed the need for counseling to continue to discuss these issues so he can get better.

Coordinated appointment with new support group at hospital for victims of abuse.

Will see again next week and on a regular schedule to continue to provide support.

Generic Synthroid (levothyroxine) given; repeat TFTs ordered.

TEST YOUR CODING SKILLS: ANSWERS

Case 1: Level 99215 was met with the comprehensive exam (two bullets from each of nine systems) and high complexity medical decision-making (possible life-threatening condition). Consider adding to the note the total time spent with the patient.

Case 2: Level 99215 was met with the comprehensive history and high complexity medical decision-making (new problem with additional workup and IV use of a controlled substance). Consider adding to the note the total time spent with the patient.

Case 3: Level 99215 was met because more than 50 percent of the total face-to-face time of > 40 minutes was spent counseling and coordinating care.

U.S. Department of Health and Human Services, Office of Inspector General. Coding trends for evaluation and management codes in all visit types from 2001 to 2010. http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf . Published May 2012. Accessed Sept. 29, 2014.

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THC emergency room visits decrease in young Virginians

CHARLOTTESVILLE, Va. (WVIR) - New data from the Virginia Hospital and Healthcare Association shows a decrease in young Virginians going to the emergency room with THC or hemp-related issues.

The data suggests the decline in hospital visits for people 18 and younger follows a new law that went into effect last July regulating these products.

“One of the reasons we share a lot of data-informed insights is because we want the public to understand those things that impact community health that impact their health,” VHAA Vice President of Communications Julian Waker said.

Walker says for years the rate of hospitalization for young Virginians exposed to THC or hemp-related products was steadily increasing.

“What our data analysis found is, in the six months after this law took effect July 2023 those numbers went down in a statistically significant way,” Walker said.

Doctor Chris Holstege, director of University of Virginia’s Blue Ridge Poison Center says the same thing is happening in Charlottesville.

“We now have seen a plateau of calls,” Dr. Holstege said.

According to Holstege’s data, from July to December of 2022 the Poison Center had 54 of these types of calls from people 18 and under. 48 of them had to go to the hospital.

During the same time in 2023, there were 60 calls but only 40 hospital visits.

“What we’ve seen is a decrease,” Dr. Holstege said. “First time that we’ve seen a decrease in children going to the emergency departments for care, and that part’s good.”

The law put tighter restrictions on how these products are sold, including their labeling and packaging.

Dr. Holstege says while this data is still fresh, it’s promising.

“We just looked at six months of data, and I’ll be curious to see once we get a year’s worth of data compared to the other years, but that part at least is encouraging that it’s plateauing or potentially dropping,” Dr. Holstege said.

Do you have a story idea? Send us your news tip here .

Copyright 2024 WVIR. All rights reserved.

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• Healthy Habits
• Healthy and Safe Swimming
• How to Respond
• Healthy Swimming Communication Resources
• Aquatics Professionals Toolkit
• Pool Inspection Toolkit
• The Model Aquatic Health Code (MAHC): A Model Public Swimming Pool and Spa Code

Swimming and Your Health

• Water-based exercise offers physical and mental health benefits, including improved health for people with chronic illnesses like diabetes, heart disease, and arthritis.
• However, recreational water can also spread illness or cause injury, so it is important to know what to do to protect yourself and others.

Health benefits

Swimming can improve mood and people report enjoying water-based exercise more than exercising on land.

People are able to exercise longer in water without increased joint or muscle pain, which has been shown to be especially helpful for people with arthritis and osteoarthritis. Water-based exercise can help people with arthritis improve the use of their arthritic joints, decrease pain, and not worsen symptoms. People with rheumatoid arthritis have shown more health improvements after participating in hydrotherapy (exercising in warm water) than with other activities.

For people with fibromyalgia, swimming can decrease anxiety, and exercise therapy in warm water can decrease depression and improve mood. Parents of children with developmental disabilities find that recreational activities, such as swimming, improve family connections.

Water-based exercise can benefit older adults by improving their quality of life and decreasing disability. It can also improve or help maintain the bone health of post-menopausal women.

Staying healthy and safe while you swim

To stay healthy and safe while you swim, it is important to understand how to prevent illness and injury when you are in or around the water.

You can get swimming-related illnesses if you swallow, have contact with, or breathe in mists of water contaminated with germs. The most common swimming-related illnesses are diarrhea , skin rashes , swimmer's ear , pneumonia or flu-like illness , and irritation of the eyes or respiratory tract .

Learn more about what you can do to prevent these illnesses when you swim and how to protect yourself depending on where you go (pool, hot tub, splash pad, ocean, etc.)

Preventing Swimming-related Illnesses

Guidelines for Healthy and Safe Swimming

Keeping your pool and hot tub clean

Having pool or hot tub can be a fun way to be active or just relax. It is important to know what to do to reduce the risk of pool-related injury and illness, as well as how to clean your pool if it has been contaminated by poop, vomit, blood, or a dead animal.

Guidelines for Keeping Your Pool Safe and Healthy

Responding to Pool Contamination

• US Census Bureau. Statistical Abstract of the United States: 2012. Arts, Recreation, and Travel: Participation in Selected Sports Activities 2009. [XLS – 40 KB] ·
• U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans: Be active, healthy, and happy! In Chapter 2: Physical Activity Has Many Health Benefits. 2009.
• Westby MD. A health professional's guide to exercise prescription for people with arthritis: a review of aerobic fitness activities. Arthritis Rheum. 2001;45(6):501-11.
• Hall J, Skevington SM, Maddison PJ, Chapman K. A randomized and controlled trial of hydrotherapy in rheumatoid arthritis. Arthritis Care Res. 1996;9(3):206-15.
• Tomas-Carus P, Gusi N, Hakkinen A, Hakkinen K, Leal A, and Ortega-Alonso A. Eight months of physical training in warm water improves physical and mental health in women with fibromyalgia: a randomized controlled trial. J Rehabil Med. 2008;40(4):248-52.
• Broman G, Quintana M, Engardt M, Gullstrand L, Jansson E, and Kaijser L. Older women's cardiovascular responses to deep-water running. J Aging Phys Act. 2006;14(1):29-40.
• Cider A, Svealv BG, Tang MS, Schaufelberger M, and Andersson B. Immersion in warm water induces improvement in cardiac function in patients with chronic heart failure. Eur J Heart Fail. 2006;8(3):308-13.
• Bartels EM, Lund H, Hagen KB, Dagfinrud H, Christensen R, Danneskiold-Samsøe B. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 2016;3:CD005523.
• Berger BG, and Owen DR. Mood alteration with yoga and swimming: aerobic exercise may not be necessary. Percept Mot Skills. 1992;75(3 Pt 2):1331-43.
• Gowans SE and deHueck A. Pool exercise for individuals with fibromyalgia. Curr Opin Rheumatol. 2007;19(2):168-73.
• Hartmann S and Bung P. Physical exercise during pregnancy—physiological considerations and recommendations. J Perinat Med. 1999;27(3):204-15.
• Mactavish JB and Schleien SJ. Re-injecting spontaneity and balance in family life: parents' perspectives on recreation in families that include children with developmental disability. J Intellect Disabil Res. 2004;48(Pt 2):123-41.
• Sato D, Kaneda K, Wakabayashi H, and Nomura T. The water exercise improves health-related quality of life of frail elderly people at day service facility. Qual Life Res. 2007;16:1577-85.
• Rotstein A, Harush M, and Vaisman N. The effect of water exercise program on bone density of postmenopausal Women. J Sports Med Phys Fitness. 2008;48(3):352-9.

Healthy Swimming

CDC’s Healthy Swimming website provides information on how to have healthy and safe swimming experiences while minimizing illness and injury.

For Everyone

Public health.

Seniors stranded in ER waiting for care suffer avoidable harm

Hospital "er boarding" is a public health crisis, especially for elderly patients, experts say..

Every day, the scene plays out in hospitals across America: Older men and women lie on gurneys in emergency room corridors moaning or suffering silently as harried medical staff attend to crises.

Even when physicians determine these patients need to be admitted to the hospital, they often wait in the ER for hours – sometimes more than a day – in pain and discomfort, not getting enough food or water, not moving around, not being helped to the bathroom and not getting the care doctors deem necessary.

ER hallways are “lined from end to end with patients on stretchers in various states of distress calling out for help, including a number of older patients,” said Hashem Zikry, an emergency medicine physician at UCLA Health.

Physicians who staff emergency rooms say this problem, known as ER boarding, is as bad as it’s ever been – even worse than during the first years of the COVID-19 pandemic, when hospitals filled with desperately ill patients.

While boarding can happen to all ER patients, adults 65 and older, who account for nearly 20% of ER visits, are especially vulnerable during long waits for care. Also, seniors may encounter boarding more often than other patients. Estimates published in 2019 suggest that 10% of patients were boarded in ERs before receiving hospital care. About 30% to 50% of these patients were older adults.

“It’s a public health crisis,” said Aisha Terry, an associate professor of emergency medicine at George Washington University and the president of the board of the American College of Emergency Physicians, which sponsored a summit on boarding in September.

Staff shortages, high demand, financial priorities

Almost a dozen doctors and researchers described the chaotic situation in ERs. They said staff shortages are contributing to the crisis. Also, they said, administrators are setting aside more beds for patients undergoing lucrative procedures, contributing to ER bottlenecks.

Then there’s high demand for hospital services, fueled in part by the aging of the U.S. population, and backlogs in discharging patients because of growing problems securing home health and nursing home care, according to Arjun Venkatesh, chair of emergency medicine at the Yale School of Medicine.

The impact of long ER waits on seniors who are frail, with multiple medical issues, is especially serious. Confined to stretchers, gurneys or even hard chairs, often without dependable aid from nurses, they’re at risk of losing strength, forgoing essential medications and experiencing complications such as delirium, according to Saket Saxena, co-director of the geriatric emergency department at the Cleveland Clinic.

When these patients finally secure a hospital bed, their stays are longer and medical complications more common. And  new research  finds that the risk of dying in the hospital is significantly higher for older adults when they stay in ERs overnight, as is the risk of adverse events such as falls, infections, bleeding, heart attacks, strokes and bedsores.

Several weeks ago, Zikry helped care for a 70-year-old woman who fell and broke her hip while attending a basketball game. “She was in a corner of our ER for about 16 hours in an immense amount of pain,” he said.

No one knows exactly how common ER boarding is and where is it most acute, because hospitals aren’t required to report that data. The Centers for Medicare & Medicaid Services retired a boarding measure in 2021. New national measures of emergency care capacity have been proposed but not yet approved.

In the meantime, some hospital systems are publicizing their plight by highlighting capacity constraints and the need for more beds. Among them is  Massachusetts General Hospital , which announced in January that ER boarding had risen 32% from October 2022 to September 2023. At the end of that period, patients admitted to the hospital spent a median of 14 hours in the ER and 26% spent more than 24 hours.

Maura Kennedy, Mass General’s chief of geriatric emergency medicine, described an octogenarian woman with a respiratory infection who languished in the ER for more than 24 hours after physicians decided she needed inpatient care.

“She wasn’t mobilized, she had nothing to cognitively engage her, she hadn’t eaten and she became increasingly agitated, trying to get off the stretcher and arguing with staff,” Kennedy said. “After a prolonged hospital stay, she left the hospital more disabled than she was when she came in.”

How to stay healthier when waiting

When asked what older adults could do about these problems, ER doctors pointed to the need for larger system and policy changes. Still, they had several suggestions.

“Have another person there with you to advocate,” said Jesse Pines, chief of clinical innovation at US Acute Care Solutions. That person should speak up if they feel you’re getting worse or if staffers are missing problems.

Alexander Janke, a clinical instructor of emergency medicine at the University of Michigan, advises people to be prepared to wait at an ER and to bring a medication list and their medications.

To stay oriented and reduce the possibility of delirium, “make sure you have your hearing aids and eyeglasses,” said Michael Malone, medical director of senior services for Advocate Aurora Health in Wisconsin and Illinois. “Whenever possible, try to get up and move around.”

Friends or family caregivers who accompany older adults to the ER should ask to be at their bedside when possible. “Try to make sure they eat, drink, get to the bathroom and take routine medications for underlying medical conditions,” Malone said.

Older adults or caregivers should try to bring “things that would engage you cognitively: magazines, books … music, anything that you might focus on in a hallway,” Kennedy said.

“Experienced patients often show up with eye masks and ear plugs” to help them rest in ERs with nonstop stimulation, said Zikry of UCLA. Finally, “bring something to eat and drink in case you can’t get to the cafeteria or it’s a while before staffers bring these to you.”

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