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EMA Sample Scenarios
The following medical and mental health scenarios are for example purposes only, to illustrate to providers the types of services EMA may cover. These example scenarios are not EMA coverage policy. MHCP, through its medical review agent, will determine actual cases based on case-by-case circumstances and medical documentation. Scenario samples below include:
Patient is treated in the emergency department for diabetic ketoacidosis. Patient is diagnosed with Type 1 insulin-dependent diabetes. Diabetic ketoacidosis is a potentially life-threatening emergency. Patient is stabilized and discharged to home. Per the treating physician’s documentation, the patient would be expected to return to a diabetic ketoacidosis state within 24-48 hours without ongoing insulin therapy. Through the care plan process, patient may be determined eligible for coverage for insulin treatment and blood glucose monitoring as well as physician visits directly related to diabetes and insulin management.
Patient presents to the emergency department with shortness of breath and angina due to pulmonary arterial hypertension. Patient has been unresponsive to standard calcium channel blocker therapy. Patient is stabilized in the hospital and discharged on a continuous infusion of prostacyclin therapy. Per the treating physician’s documentation, the patient would be expected to return to the emergency department with pulmonary arterial hypertension symptoms within 12-24 hours of discontinuation of prostacyclin therapy. Through the care plan process, patient may be eligible to receive coverage for the continuous prostacyclin therapy and associated equipment, as well as physician visits directly related to the management of the pulmonary arterial hypertension.
Patient was in a motor vehicle accident and sustained injuries, including a broken collarbone. Patient is treated in the emergency department for the injuries and is discharged to home. As a result of the broken bone, patient has severe pain and would likely return to the emergency department for pain relief within 12-24 hours without pain medication. Through the care plan process, patient may be eligible to receive coverage of pain medication and muscle relaxers to treat the severe pain during the healing period for the broken bone (typically 6-8 weeks).
After 6 weeks, the patient presents with limited shoulder range of motion as a result of the immobilization necessary to allow healing of the collarbone. The physician recommends physical therapy, however, the physician is not able to document that without the physical therapy services, the patient’s condition would, within 24-48 hours, place the patient’s health in serious jeopardy, cause serious impairment to bodily functions or serious dysfunction of any bodily organ or part. The physical therapy services would not be covered under EMA because the limited range of motion in the shoulder is not an emergency medical condition.
Patient presents to the emergency department with complaints of chest pain. After workup in the emergency department, it is determined that the chest pain was a result of indigestion and heartburn and was not cardiac in nature. Patient is treated in the emergency department with an antacid and symptoms are resolved. Patient is discharged to home with information about dietary interventions to reduce the risk of heartburn and prescriptions for ranitidine and Tums® tablets. Although the emergency department visit would be covered under EMA, the prescriptions would not be covered under EMA because heartburn is not an emergency medical condition.
Patient presents to the emergency department with multiple worsening symptoms including fatigue, jaundice, weight loss, nausea, confusion, edema of the extremities and difficulty sleeping. The patient has a diagnosis of end stage renal disease and is admitted to the hospital. The patient’s condition is stabilized and the patient is discharged to home. The attending physician has documented the need for outpatient hemodialysis 3 times per week to prevent placing the patient’s health in serious jeopardy due to renal failure, which would likely occur within 48-72 hours. Through the care plan process, patient may be eligible to receive coverage for the outpatient dialysis treatment.
Mental Health Scenarios
Patient presents to the emergency department with suicidal gestures and attempts. Patient has been unresponsive to mobile crisis stabilization services. Patient is admitted for inpatient psychiatric care for stabilization and treatment services, including the use of fluoxetine. Patient was diagnosed with major depression. As documented by the emergency department physician, the patient is at risk of serious harm to self unless admitted for psychiatric care. The patient is stabilized in the inpatient environment on fluoxetine. The psychiatrist’s documentation indicates that without ordered outpatient therapy and continued use of fluoxetine, the patient will likely need re-hospitalization within 24-48 hours. Through the care plan process, the patient’s outpatient treatment and fluoxetine prescription may be eligible for EMA coverage.
Child presents to the emergency department with fire setting behavior, which resulted in major damage to the family’s garage. Child is admitted for inpatient psychiatric care for stabilization and treatment services. Child was diagnosed with post-traumatic stress disorder. As documented by the emergency department physician, the child is at risk of serious harm to self and his family. After the child was stabilized with the use of risperdone, the child was recommended for long-term mental health treatment. County conducted a screening to determine level of care. The psychiatrist’s documentation indicates that without treatment and medication, the patient’s condition would deteriorate to an emergency condition within 24 hours. Through the care plan process, patient’s treatment and risperdone prescription may be eligible for EMA coverage.
Patient presents to the emergency department with psychotic behavior in believing he should kill his mother. Patient is admitted for inpatient psychiatric stabilization and treatment services and has a schizoaffective disorder. As documented by the emergency department physician, the patient is dangerous to his mother and receives medication to decrease his thoughts of hurting her. To prevent re-hospitalization within 12-24 hours of discharge, the physician ordered outpatient therapy and continued use of clozapine along with with necessary lab work. Through the care plan process, patient’s outpatient therapy, clozapine prescription, and associated lab work may be eligible for EMA coverage.
Female patient presents to the emergency department with psychotic behavior to harm her child or herself. Patient is diagnosed with maternal depression and admitted for inpatient psychiatric stabilization and treatment services. As documented by the emergency department physician, patient is a harm to self and her child and receives medication to treat her depression. The psychiatrist has documented that the patient would likely require re-hospitalization within 12-24 hours of discharge without continued medication and outpatient therapy. Through the care plan process, the patient’s ordered outpatient therapy and sertraline prescription may be eligible for EMA coverage.
Long Term Care (LTC) Scenarios
Recipient was involved in a car accident on 6/5/2008 and admitted to the hospital. The accident caused a spinal cord injury that resulted in quadriplegia and a tracheostomy. He was discharged to a nursing home after a 30-day stay in the hospital to continue care because of the emergency medical condition. He needs assistance with all of his daily cares. Nursing staff provide suctioning more than six times per day to keep the trach clear. If the recipient did not receive this kind of care, he would have a medical emergency within 48 hours. Through the care plan process, the recipient’s nursing facility services may be eligible for EMA coverage.
A 69-year-old woman was diagnosed with dementia by her primary care physician in 2010. She was living with her daughter and family until 5/22/11. She was admitted to a specialized nursing home for Alzheimer’s. The family was no longer able to care for her at home due to wandering, combativeness and other safety issues. Through the care plan process, the recipient would not meet care plan certification because her condition was not initially treated in the ED or inpatient hospital.
Recipient was diagnosed during an inpatient hospital stay with ALS in 2010. He lives at home with family. His wife is able to provide some of his care in addition to PDN and PCA services. He has a tracheostomy, ventilated up to 20 hours/day and receives nutrition and medications through a GJ tube. He is able to take some nutrition orally with 1:1 assist to monitor aspirations. He requires sterile suctioning and nebulizer treatments daily. Through the care plan process, the recipient’s home care services for ALS may be eligible for EMA coverage.
Treatment for dental emergencies is to be provided at a dental clinic. Hospital emergency departments are not staffed with dentists. Recipients with dental emergencies are to present at the emergency department when their health is in serious jeopardy. In these types of very limited cases, medical providers may be involved with treatment.
Dental emergency treatment is typically limited to emergency evaluations, x-rays necessary to diagnose the existing emergency condition, extractions, and prescriptions for antibiotics.
Recipient presents to the dental clinic with acute pain and swelling of the upper right area of the mouth and face. The dentist completes a limited oral evaluation which includes an x-ray of the involved tooth and diagnoses an abscessed upper right molar. An extraction of the tooth is completed and a prescription for antibiotics and pain control is prescribed. Through the care plan certification process, EMA would cover the limited oral evaluation, periapical x-ray and extraction. The recipient may be determined eligible for antibiotic coverage during the healing process of the acute infection (typically a week to 10 days). The prescription for pain control would not be EMA covered because minor pain and discomfort that may follow an extraction is not an emergency medical condition.
Patient was in a motor vehicle accident and sustained facial abrasions and oral injuries that are limited to chipped teeth. The patient was evaluated, treated, and released from the hospital emergency department and it was suggested that the patient see a dentist for an evaluation of her chipped teeth. Three days later, the patient presents to the dentist for an oral evaluation with a chief complaint of sore gums and chipped teeth. The dentist completes an oral evaluation, x-rays of the involved area and recommends that the patient return for fillings to repair the chipped teeth. EMA would not cover the dental services because sore gums and chipped teeth are not an emergency medical condition.
The patient presents to the emergency department with acute pain and visible swelling in upper left area of her face and mouth. The swelling extends into the area of the eye. The skin is red and feels warm. The physician diagnoses facial cellulitis caused by infected teeth. The patient is admitted to the hospital, treated for the cellulitis and is discharged after 3 days with a prescription for an antibiotic. The patient will likely need re-hospitalization if the infected teeth are not removed; therefore, the patient is referred to an oral surgeon for further treatment. The patient is seen by an oral surgeon on the day of discharge from the hospital. The oral surgeon completes a limited oral evaluation, panoramic x-ray and extraction of two upper left molars related to the episode of cellulitis. Additional medications are not prescribed at the time. Through the care plan certification process, EMA would cover the hospital inpatient services associated with the severe infection including the prescription provided upon hospital discharge. EMA would also cover the services completed by the oral surgeon and potentially, additional antibiotic during the healing process.
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