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Emergency departments (EDs) have been a hot-button topic in the battles over “surprise” billing. 

Certainly, many patients use EDs inappropriately. We’ve all read and heard about uninsured patients, patients with no primary care provider, patients who simply abuse the fact that EDs are always open, patients with complaints that are clearly not emergencies, etc. Getting even more attention of late are insurance plans idiosyncratically deciding what is and what is not an emergency. What is not being discussed about the surprise billing issue is the often poor hospital coding that can incorrectly list non-covered emergency services. 

The Prudent Layperson Standard has been in effect under federal and most state laws for many years. The very essence and intent are to protect patients who use good common sense as a layperson in determining if an emergency exists. The other guiding principle is that such a determination is based upon the presenting symptoms, not Monday-morning quarterbacking by insurance companies based on the final diagnosis from the emergency department physician. The fact is that many times, the emergency physician does not know if the symptoms are indicative of a potentially life-threatening problem or a relatively benign issue until after the evaluation and diagnostic workup are complete.

Now, let’s enter coding into the equation. The first problem we hear all the time involves the ED physician’s frustration with trying to find the correct ICD-10-CM code for the signs, symptoms, or diagnosis; apparently, they certainly don’t have time to wade through the coding rules if they do find it. Some electronic health record (EHR) code lists begin with unspecified choices. Some facilities permit their physicians to choose their own list of favorites.

The second problem is facility coders who have been trained to always use the final diagnosis and not the presenting complaint(s) when coding. Many are not familiar with and have not been educated on the Prudent Layperson Standard. As a result, truly emergent visits are not coded to accurately reflect why the patient came to the ED. Compounding this specific problem, facilities often refuse to reevaluate the record and assigned coding when patients receive surprise bills based on non-emergent diagnoses.

The final coding issue is insurance plans’ refusal to review the medical record if the patient argues that the visit was an emergency and met both the coverage policy and the Prudent Layperson Standard. It seems that insurance plans are fully invested in arguing that the coding is just about always correct, and no actions or medical record review are needed when patients complain.

As just one example, on one weekend a young boy suddenly developed a high fever, was unresponsive to antipyretics, had swollen glands and profuse vomiting, and was covered from head to foot with hives. I think anyone with an iota of common sense would believe this was an emergency. The ED provider certainly thought it was, and told the mother he was worried about meningitis and other serious illness, so a full work-up ensued. Intravenous fluids were needed for dehydration and multiple medications were administered. Finally, it was determined the symptoms were due to a virus. And that is what the facility coded: unspecified virus. The patient’s mother witnessed every one of the above-cited issues. Even though she is a certified coder, trainer, and auditor, her concerns fell on deaf ears. It never crossed her mind that the ED visit would be deemed “non-emergent,” and she had to pay her surprise bill of several thousand dollars.

Coders need to be educated on correctly reporting why patients present to emergency departments, consistent with the Prudent Layperson Standard. Facilities need to have procedures to thoughtfully review and address concerns when emergency coding is challenged. There needs to be standardized, consistently applied coding and coverage criterion, and a swift end to the current insurance practices of denying prudent layperson claims. Unless and until this root cause of surprise bills is addressed, we are missing a golden opportunity to help solve the problem.



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