Emergent or Urgent?

Definition

Per Medicare:

Emergency care services means inpatient or outpatient hospital services that are necessary to prevent death or serious impairment of health and, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services. 

Per Medi-Cal:

Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following: 

• Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy. 
• Serious impairment to bodily functions. 
• Serious dysfunction of any bodily organ or part.

Definition

Per Medicare:

Urgent care services means services furnished to an individual who requires services to be furnished within 12 hours in order to avoid the likely onset of an emergency medical condition.    

Per Medi-Cal:

Urgent care means an episodic physical or mental condition perceived by a member as serious but not life threatening that disrupts normal activities of daily living and requires assessment by a health care provider and if necessary, treatment within 24-72 hours. 

According to Mount Sinai Health Systems, some examples of conditions that require emergent care are:

• Severe chest pain or difficulty breathing
• Compound fracture (bone protrudes through skin)
• Convulsions, seizures or loss of consciousness
• Fever in newborn (less than 3 months old)
• Heavy, uncontrollable bleeding
• Deep knife wounds or gunshot wounds
• Moderate to severe burns
• Poisoning
• Serious head, neck or back injury
• Pregnancy-related problems
• Severe abdominal pain
• (Signs of) Heart attack (i.e. chest pain lasting longer than two minutes)
• (Signs of) Stroke (e.g. loss of vision, sudden numbness, weakness, slurred speech, or confusion)
• Suicidal or homicidal feelings

A psychiatric emergency is when a person is at immediate risk of serious harm to self or others as a result of a mental disorder and requires immediate, continuous skilled observation at the acute level of care.

According to Mount Sinai Health Systems, urgent medical conditions are ones that are not considered emergent but still require care within 24 hrs. Some examples of such conditions include:
• Accidents and falls
• Sprains and strains
• Moderate back problems
• Breathing difficulties (i.e. mild to moderate asthma)
• Bleeding/cuts -- not bleeding a lot but requiring stitches
• Diagnostic services, including X-rays and laboratory tests
• Eye irritation and redness
• Fever or flu
• Vomiting, diarrhea or dehydration
• Severe sore throat or cough
• Minor broken bones and fractures (i.e. fingers, toes)
• Skin rashes and infections
• Urinary tract infections

A Medicare example of urgent care is if a beneficiary has an ear infection with significant pain, CMS would view that as requiring treatment to avoid the adverse consequences of continued pain and perforation of the eardrum. The patient’s condition would not meet the definition of emergency medical condition because immediate care is not needed to avoid placing the health of the individual in serious jeopardy or to avoid serious impairment or dysfunction. However, although it does not meet the definition of emergency care, the beneficiary needs care within a relatively short period of time (which CMS defines as 12 hours) to avoid adverse consequences, and the beneficiary may not be able to find another physician or practitioner to provide treatment within 12 hours.