CMS shines light into the gray areas of EMTALA rule

Everyone in health care still is sorting through exactly what the final Emergency Medical Treatment and Labor Act (EMTALA) rule means, and apparently the surveyors working for the federal Centers for Medicare & Medicaid Services (CMS) are no different.

CMS recently issued a guidance memo to state survey agency directors that may provide some insight into how surveyors will interpret your own operations when it comes to those gray areas. The guidance memo instructs surveyors on how to interpret some points that have been confusing or represent a departure from previous versions of EMTALA. Revised interpretative guidelines for EMTALA are being developed and will be the more official instructions to surveyors, but "in the meantime, the attached interim guidance is being provided to surveyors to use when conducting an investigation and assessing a hospital’s compliance with EMTALA," according to the cover letter from Thomas E. Hamilton, director of the CMS survey and certification group.

Guidance memo highlights

These are some of the points addressed in the guidance memo:

Locations on-campus other than the "dedicated emergency department": "Persons [including visitors] presenting themselves at an area of a hospital on the hospital’s main campus other than a dedicated ED must receive a medical screening exam only if they request, or have a request made on their behalf, for examination or treatment for what may be an emergency medical condition. Where there is no verbal request, a request will nevertheless be considered to exist if a prudent layperson observer would conclude, based on the person’s appearance or behavior, that the person needs emergency examination or treatment."

Other locations off campus: "If a request were made for emergency care in a hospital department off the hospital’s main campus other than a dedicated ED, EMTALA would not apply. The off-campus facility should call the local emergency medical service [EMS] to take the individual to an emergency department (not necessarily the emergency department of the hospital that operates the off-campus department, but rather the closest emergency department) and should provide whatever assistance is within its capability. Therefore, an off-campus location that does not meet the definition of a dedicated ED is not required to be staffed to handle potential EMC [emergency medical conditions]. However, under the conditions of participation [COPs] at 42 C.F.R. 482.12 (f)(3), such departments are required to have written policies and procedures for appraisal of emergencies and referrals when appropriate."

When a patient is admitted: The rule states that a hospital’s EMTALA obligation ends toward an individual when the individual has been admitted for inpatient hospital services, whether the individual has been stabilized. The guidance memo said, "A patient is considered to be admitted’ when the decision is made to admit the individual to receive inpatient hospital services with the expectation that the patient will remain in the hospital at least overnight. Typically, we would expect that this would be documented in the patient’s chart and medical record as the time that the admitting physician signed and dated the admission order."

When a patient is considered stable: "To be considered stable, a patient’s emergency medical condition must be resolved, even though the underlying medical condition may persist. For example, an individual presents to a hospital complaining, of chest tightness, wheezing, shortness of breath, and has a medical history of asthma. A physician completes a medical screening examination and diagnoses the individual as having an asthma attack which is an emergency medical condition. Stabilizing treatment is provided [medication and oxygen] to alleviate the acute respiratory symptoms. In this scenario the EMC was resolved, but the underlying medical condition of asthma still exists. After stabilizing the patient, the hospital no longer has an EMTALA obligation. The physician may discharge the patient home, admit him/her to the hospital, or transfer [the "appropriate transfer" requirement under EMTALA does not apply to this situation since the patient has been stabilized] the patient to another hospital depending on his/her needs or request."

Three ways to end EMTALA obligation: The guidance memo noted that a hospital’s EMTALA obligation ends when a physician or qualified medical person makes any one of these three decisions:

1. No emergency exists.

2. An emergency exists which requires transfer to another facility, or the patient requests transfer to another facility. (The EMTALA obligation rests with the transferring hospital until arrival at the receiving hospital.)

3. An emergency exists and the patient is admitted to the hospital for further stabilizing treatment.

For the full guidance memo, go to and search for "Emergency Medical Treatment and Labor Act (EMTALA) Interim Guidance (S&C 04-10).