Getting on Board- the Problem with ED Boarding

Getting on Board

Understanding precisely what the phenomenon of “ED boarding” means is vital to managing proper placement of patients.

I was recently asked by Christine in Minnesota the following question: “our billers think the ED patient has to stay past midnight to be an ED boarder; is that true? Have you written anything about ED boarding?”

Christine, let me start with this. The term “ED boarding” does not exist in the Medicare regulatory language the way most look at it. What the Centers for Medicare & Medicaid Services (CMS) and other organizations such as the Joint Commission often discuss is ED throughput, and they consider ED boarding a measure of the time from the decision to admit to the time of transportation of the patient to that location.

ED boarding is not inherently a bad thing, as it is often portrayed. By the CMS standard, the patient who went to their inpatient bed two hours after the inpatient order was placed had an ED boarding time of two hours. Now, is an ED boarding time of two hours a problem? Well, for most patients it isn’t. Heck, it is probably a really short time period. But for the patient in septic shock, on a ventilator and on pressors, they probably should have been moved to the ICU sooner than that. So, talking about ED boarding has to be kept in context. ED boarding is bad only when it has the potential to result in adverse effects.

Now, just because benchmarking and key performance indicators are ubiquitous in healthcare, the Joint Commission made ED boarding a measure, and set a goal at four hours for admission decision until transfer. But they make it very clear that this is set as a “reasonable goal,” and that the four-hour time frame is not being imposed as a national target or requirement for accreditation.

Of course, the reason for reducing prolonged ED boarding is related to patient safety, with several studies showing an increase in medical errors and mortality with increased ED boarding times and patient volume. And it goes without saying that there is no easy solution. If a skilled nursing facility (SNF) or home care agency is at capacity, then they cannot admit new patients, and that means hospitalized patients continue to occupy their beds and ED patients are stuck boarding in the ED.

But back to the concept of ED boarding. While ED boarding time may be a quality measure for CMS and the Joint Commission, from a billing standpoint, ED boarding does not exist. An ED patient’s care is billed as an ED encounter up until the point that either they are admitted as an inpatient pursuant to an inpatient admission order or they begin receiving observation services pursuant to an order for observation services (or they are transferred out of the ED to the pre-op area, another hospital, or even upstairs for custodial care). If none of these happens, they remain an ED patient.

ED boarding is not billed as a status or service. Payor policy can be viewed as location-agnostic. If the patient is formally admitted as an inpatient, then they are an inpatient, regardless of whether they are boarding in the ED, in an inpatient bed, or receiving care in a makeshift inpatient unit in a tent in the parking garage. Likewise for observation care. While they may disregard the location, most payers would expect the care to be transferred to the appropriate physician. In other words, the inpatient boarding in the ED should be under the care of a physician with admitting privileges, and not cared for by the ED physician. That physician should bill for their services based on the patient status and not location, and the facility can start counting observation hours or inpatient days with the appropriate order.

Now, unlike facility charges for inpatient or observation or surgery recovery time, all of which are billed by units of time (minutes, hours, or days), and being theoretically unlimited, ED facility billing is based on services provided to the patient during the encounter, without any regard to time. One ED visit, be it four hours or four days, generates one unit of ED care. That might be seen as another incentive to reduce ED boarding.

We often see patients requiring psychiatric care remaining in the ED for days on end, awaiting an opening in a psychiatric facility. Many hospitals choose not to admit these patients as inpatients despite their need for inpatient psychiatric care, as that bumps them off the transfer list. As a result, they remain either ED patients or, alternatively, outpatients with observation services. Using observation does allow the facility to charge an hourly rate for monitoring, and for physicians to use the evaluation and management (E&M) codes appropriate for observation services for their visit. While observation is supposed to be a time-limited service, this is one area in which continuing such care over the specified time limit makes sense – unlike our society’s ability to provide proper psychiatric care to all patients who require it.

So, to sum up, ED boarding may be a bad thing because of the adverse effects on patient safety and quality, and the staff stressors from caring for many more patients than is safe, but it is not a status and does not affect how the care is billed.

Continue to optimize your facility’s lengths of stay with timely transitions of care to the next setting and avoidance of unnecessary hospital care – but bill for the care based on their orders, not their location.  

Programming note: Listen to Dr. Ronald Hirsch as he makes his rounds during Monitor Mondays at 10 a.m. EST, sponsored by R1-RCM.


Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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